SURGERY  OF  THE  UPPER  ABDOMEN 


DEAVER  AND  ASHHURST 


SURGERY  OF  THE 
UPPER  ABDOMEN 


BY 

JOHN  B.  bEAVER,  M.D.,  Sc.D.,  LL.D.,  F.A.C.S. 

Barton  Professor  of  Surgery  in  the  University  of  Pennsylvania, 

Surgcon-in -Chief  to  the  Latikenaii  Hospital,  and  Surgeon 

in  the  University  Hospital 


AND 


ASTLEY  PASTON  COOPER  ASHHURST,  A.  B.,  M.D.,  F.A.C.S. 

Associate  in  Surgery  in  the  University  of  Pennsylvania, 

Surgeon  to  the  Episcopal  Hospital,  Philadelphia, 

Colonel,  Medical  Reserve  Corps,  U .  S.  Army 


SECOND  EDITION 
WITH  9  COLORED  PLATES  AND  198  OTHER  ILLUSTRATIONS 


PHILADELPHIA 

BLAKISTON'S   SON    &    CO. 

1012    WALNUT    STREET 


COPYKIGHT,    192I,   BY    P.    BLAKISTON'S    SoN    &    CO. 


r  U  K     M  A 


P  I,  K     />  R  K  S  S     YORK.     1'  A 


TO  THE 
MEMORY  OF 

AGNEW 
ASHHURST 


I^SL  I 


PREFACE  TO  SECOND  EDITION 


The  first  edition  of  this  work  was  pubhshed  in  two  volumes:  the 
first  volume,  comprising  the  surgery  of  the  stomach  and  duodenum, 
appeared  in  1909;  and  the  second,  which  included  the  surgery  of  the 
gall-bladder,  Hver,  pancreas  and  spleen,  in  1913.  So  very  favorable 
was  its  acceptance  by  the  profession,  that  the  publishers  soon  called 
for  another  edition;  and  work  on  the  revision  was  well  advanced  when 
interrupted  by  the  war.  During  the  two  years  since  the  armistice 
the  revision  has  been  resumed. 

While  the  general  plan  of  the  book  remains  unaltered,  many  sections 
have  been  entirely  rewritten  (e.g.,  gastric  ulcer,  infantile  stenosis  of 
the  pylorus,  chronic  dilatation  of  the  duodenum,  causes  of  death 
after  operations  on  the  stomach  and  duodenum,  jejunal  and  gastro- 
jejunal  ulcer,  etc.),  much  new  material  added  {e.g.,  in  the  chapters 
dealing  with  operative  technique,  particularly  the  transgastric  excision 
of  ulcers,  resection  of  the  descending  duodenum,  cholecystectomy  and 
operations  on  the  bile-ducts,  and  the  surgery  of  the  spleen),  and  some 
that  was  obsolete  omitted.  The  first  edition  contained  extensive 
bibliographical  references,  most  of  which  are  of  historic  interest  only, 
and  therefore  are  not  republished  in  this  new  edition.  The  dates  of 
publication  of  papers  of  value,  however,  have  been  included  in  the 
text;  thus  the  original  references  may  readily  be  found,  by  those 
interested,  in  the  Index  Medicus  or  the  Index  Catalogue  of  the  Library 
of  the  Surgeon  General's  Office,  United  States  Army.  Statistical 
tables  published  at  length  in  the  first  edition  have  been  condensed  or 
summarized,  and  whenever  possible  have  been  superseded  from  the 
growing  statistics  available  especially  from  the  senior  author's  service 
at  the  Lankenau  Hospital.  Moreover,  by  the  use  of  a  slightly  larger 
page,  considerable  space  has  been  gained,  so  that  it  is  now  possible  to 
present  in  a  single  volume  of  slightly  over  800  pages  more  material 
than  was  formerly  included  in  two  volumes  running  almost  to 
a  thousand  pages. 

Much  consideration  has  been  given  to  the  matter  of  illustrations; 
nearly  one  hundred  new  drawings  have  been  introduced,  most  of 
them  from  the  skilful  pen  of  Mr.  E.  F.  Faber,  and  many  of  them  from 
preparations  by  the  junior  author. 

vii 


Vm  PREFACE 

Analysis  of  the  literature  which  has  appeared  during  the  last  ten 
years  has  been  no  light  task;  and  without  the  intelUgent  and  capable 
assistance  of  Miss  A.  M.  Jastrow  it  could  not  have  been  accomplished. 
All  the  references  have  been  verified  by  the  junior  author.  Thanks 
are  also  due  to  Miss  Edna  Patterson  for  her  continued  assistance  in 
preparing  the  manuscript  for  the  press.  Dr.  A.  D.  Whiting  has  again 
consented  to  prepare  the  Indices,  and  has  fulfilled  his  undertaking  in  a 
manner  that  adds  inestimably  to  the  value  of  the  volume. 

J.  B.  D. 
A.  P.  C.  A. 


CONTENTS 


PART  I 

Surgery  of  the  Stomach  and  Duodenum 
Chapter  Page 

I.  Anatomy i 

II.  Physiology 31 

III.  General  Diagnostic  Considerations 53 

IV.  Gastric  Ulcer 67 

V.  Pyloric  Obstruction  and  Gastric  Dilatation: 

Infantile  Stenosis  of  the  Pylorus 131 

Pylorospasm 141 

Acute  Dilatation  of  the  Stomach 142 

Atonic  Dilatation  of  the  Stomach 150 

Secondary  Gastric  Dilatation 153 

Gastroptosis 165 

VI.  Obstruction  of  the  Cardiac  Orifice  of  the  Stomach: 

Congenital  Imperforation  of  the  Esophagus 171 

Cardiospasm 173 

Cicatricial  Contraction  of  the  Cardia 176 

VII.  Hour  Glass  Stomach 178 

Gastric  Diverticula 188 

VIII.  Benign  Diseases  of  the  Duodenum: 

Duodenal  Ulcer igo 

Miscellaneous  Affections  of  the  Duodenum 200 

IX.  Benign  Tumors  of  the  Stomach  and  Duodenum 205 

X.  Tuberculosis  of  the  Stomach 221 

Syphilis  of  the  Stomach 224 

Phlegmonous  Gastritis 227 

Volvulus  of  the  Stomach 230 

Eventration  of  the  Diaphragm 23s 

Diaphragmatic  Hernia 237 

XI.  Carcinoma  of  the  Stomach 244 

XII.  Carcinoma  of  the  Duodenum 279 

Sarcoma  of  the  Duodenum 281 

Sarcoma  of  the  Stomach 281 

Endothelioma  of  the  Stomach 283 

XIII.  Injuries  of  the  Diaphragm 284 

Injuries  of  the  Stomach 288 

Injuries  of  the  Duodenum 306 

XIV.  Technique  of  Operations  on  the  Stomach  and  Duodenum 309 

Preparation  for  Operation 309 

Operative  Technique  in  General 310 

After-treatment 316 

Gastrotomy 316 

ix 


X  CONTENTS 

Chapter  Page 

Gastrostomy 318 

Esophagoplasty 322 

Pyloroplasty 326 

Gastro-jejunostomy 331 

Gastroplasty 34S 

I       Gastro-gastrostomy 345 

Gastro-anastomosis 346 

Gastro-plication 347 

Gastropexy 347 

Gastrectomy 347 

Pylorectomy  (Billroth  I) 349 

Partial  Gastrectomy  (Kocher) 351 

Partial  Gastrectomy  (Billroth  II) 353 

Partial  Gastrectomy  (Polya) 357 

Total  Gastrectomy 360 

Cylindrical  Gastrectomy 361 

Gastric  Resection 363 

Resection  of  the  Cardia 366 

Excision  of  the  Descending  Duodenum 367 

Jejunostomj' 369 

XV.  Complications  and  Sequels  of  Operation: 

Causes  of  Death  after  Operation 371 

Vicious  Circle 380 

Gastro- jejunal  and  Jejunal  Ulcer 389 

Internal  Hernia 396 

Gastric  Fistula 397 

Duodenal  Fistual 401 

Subphrenic  Abscess 402 


PART  II 

Stjrgery  of  the  Gall-bladder,  Liver,  Pancreas  and  Spleen 

XVI.  Surgical  Diseases  of  the  Biliary  Tract: 

General  Considerations 4x5 

Gall-stone  Formation 419 

Typhoid  Infections  of  the  Biliary  Tract 427 

Significance  of  Jaundice 434 

XVII.  Surgery  of  the  Gall-bladder  and  Bile-ducts: 

Deformities,  Anomalies  and  Malpositions 441 

Cholangeitis  and  Cholecystitis 444 

Cholelithiasis 460 

Non-calculous  Obstruction  of  the  Bile-ducts 506 

Biliary  Fistula 524 

Intestinal  Obstruction  from  Gall-stones 530 

XVIII.   Surgery  of  the  Liver: 

Anomalies  of  Size,  Shape,  and  Position S34 

Abscess 540 

Cirrhosis 553 

Hydatid  Cysts SS9 

Non-parasitic  Cysts 573 


CONTENTS  XI 

Chapter  Page 

XIX.  Tumors  of  the  Liver,  Gall-bladder  and  Bile-ducts: 

Adenoma  of  the  Liver 574 

Gumma   of  the  Liver 576 

Tuberculoma  of  the  Liver 577 

Sarcoma  of  the  Liver 577 

Carcinoma  of  the  Liver *   ■    ■  579 

Tumors  of  the  Gall-bladder  and  Bile-ducts 583 

XX.  Injuries  of  the  Liver 593 

Injuries  of  the  Gall-bladder  and  Biliary  Passages 607 

XXI.  Surgery  of  the  Pancreas; 

Historical 611 

Congenital  Anomalies,  Displacements,  etc 612 

Pathogenesis  of  Infections 614 

General  Diagnostic  Considerations 626 

Acute  Pancreatitis 636 

Abscess  and  Gangrene 654 

Chronic  Pancreatitis 658 

Pancreatic  Calculi 683 

Injuries 689 

XXII.  Tumors  of  the  Pancreas: 

Carcinoma 6gi 

Sarcoma 703 

Cysts 704 

XXIII.  Surgery  of  the  Spleen: 

Anatomy 717 

Physiology 719 

General  Considerations  of  Enlargements  of  the  Spleen 723 

Movable  Spleen 728 

Cysts 732 

Tumors 735 

Tuberculosis 735 

Syphilis 736 

Abscess 736 

Splenic  Anemia  (Banli's  Disease) 739 

Hemolytic  Icterus 750 

Malarial  Splenomegaly 752 

Pernicious  Anemia 752 

Myelocytic  Leukemia 754 

Cirrhosis  of  the  Liver  with  Splenomegaly 754 

Injuries 754 

Aneurysm  of  the  Splenic  Artery.   ' 759 

XXIV.  Technique  of  Operations: 

General  Considerations 760 

Operations  on  the  Gall-bladder  and  Bile-ducts: 

Abdominal  Incisions 761 

Cholecystendysis 766 

Cholecystostomy 767 

Cholecystectomy 773 

Choledochotomy 777 

Cholecystenterostomy 787 


XU  CONTEXTS 

Chapter  XXIV  (Continued)  Page 

Operations  on  the  Liver: 

Hepatopexy 790 

Transpleural  Hepatotomy 791 

Hepatectomy 793 

Operations  on  the  Pancreas: 

Pancreatectomy 795 

Pancreato-enterostomy 799 

Operations  on  the  Spleen: 

Splenectomy 799 

Splenotomy 803 

Splenopexy      804 

Index  of  Names 805 

General  Index 819 


LIST  OF  ILLUSTRATIONS 


Figure  Tage 

1.  Dissection  of  the  Abdominal  Wall;  Transversalis  Muscle  and  Lower  Intercostal 

Nerves 2 

2.  Dissection  of  the  Abdominal  Wall:  the  Lower  Intercostal  Nerves  entering  the 

Rectus  Muscle 3 

3.  Diagram  of  Early  Stage  of  Development;  the  Abdominal  Viscera 7 

4.  Diagram  Showing  Relation  in  the  Fetus  of  the  Duodenum  to  the  Liver   and 

Pancreas 8 

5.  Diagram  Representing  Early  Stage  of  Rotation  of  the  Abdominal  Viscera  ...  9 

6.  Diagram  Representing  Later  Stage  of  Rotation  of  the  Abdominal  Viscera  ...  10 

7.  Diagrammatic  Outline  of  the  Stomach 12 

8.  Lymphatic  Areas  of  the  Stomach      14 

g.  Stomach  and  Gastrohepatic  Omentum 15 

10.  Lesser  Peritoneal  Cavity  Exposed  through  the  Gastro-colic  Omentum     ....  15 

11.  Posterior  Gastric  Wall  Exposed  through  the  Inter-colo-epiploic  Route   ....  16 

12.  Diagram  of  Peritoneal  Reflections  in  Median  Sagittal  Section 17 

13.  Diagram  of  Peritoneal  Reflections  in  a  Horizontal  Transverse  Section  Passing 

through  the  Pylorus 19 

14.  Diagram  of  Peritoneal  Reflections  in  Transverse  Horizontal  Section  through  the 

Head  of  the  Pancreas 20 

15.  Diagram  of  Peritoneal  Reflections  after  Removal  of  All  Viscera 21 

16.  The    Bile-Ducts    and    their    Relation    to    the    Duodenum    and    Pancreas  .    .  22 

17.  Interior  of  Stomach,  Pylorus  and  Duodenum,  showing  Papilla  of  Vater,  also 

Orifice  of  Duct  of  Santorini 23 

18.  The  Origin  of  the  Jejunum  and  the  Duodeno-jejunal  Fossa 28 

19.  The  Pancreas,  Its  Ducts,  and  their  Relation  to  the  Duodenum      29 

20.  Graphic  Representation  of  the  Bacterial  Content  of  the  Gastro-intestinal  Tract 

(Gilbert  and  Domenici) 41 

21.  Diagram  to  Show  the  Relation  of  the  Lobes  of  the  Liver  to  Various  Abdominal 

Structures,  Indicated  by  Blood  Currents  in  the  Portal  Vein 42 

22.  Outlines  of  Normal  Stomach  ,  Resting      45 

23.  Outlines  of  Normal  Stomach,  Showing  Peristaltic  Contraction 4(> 

24.  Diagram  of  the  Stomach  Tube  in  situ      60 

25.  Skiagraph  of  Stomach,  showing  Normal  Peristalsis  {Cole) 62 

26.  Skiagraph  of  Stomach,  showing  Ulcer  on  Lesser  Curvature  (Cole)      63 

27.  Diagram  Indicating  Sites  of  268  Gastric  and  Duodenal  Ulcers 71 

28.  Ulcer  on  the  Lesser  Curvature  of  Stomach 72 

29.  Ulcers  each  Side  of  Cardiac  Orifice  of  Stomach      72 

30.  Gastrectomy  Specimen:  Callous  Ulcer  of  Anterior  Wall 74 

31.  Same  Specimen  shown  in  Fig.  30,  Opened 76 

32.  Microphotograph  of  a  Chronic  Gastric  Ulcer 77 

3S-  Microphotograph  of  a  Chronic  Gastric  Ulcer,  showing  the  Edema  which  occurs 

during  Acute  Exacerbations 78 

34.  Diagram  Indicating  Sites  of  25  Perforated  Gastric  and  Duodenal  Ulcers     ...  84 

35.  Rupture  of  a  Varicose  Gastric  Vein  near  the  Cardia 95 

36.  Skiagraph  Three  Years  after  Gastrojejunostomy,  showing  Ulcer  on  Lesser  Curva- 

ture,  still  Unhealed   (Cole) 112 

xiii 


XIV  LIST    OF    ILLUSTRATIONS 

Figure  Page 

37.  Infantile  Stenosis  of  the  Pylorus  (Caiilley  and  Dent) 133 

38.  Rammstedt's  Method  of  Pyloroplasty 139 

39.  Rammstedt's  Method  of  Pyloroplasty 139 

40.  Strauss's  Jlethod  of  Pyloroplasty 140 

41.  Acute  Dilatation  of  the  Stomach  {Thompson) 145 

42.  Perigastric  Adhesions  {Andreu's) 156 

43.  Various  Degrees  of  Gastroptosis 166 

44.  Exposure  of  Cardiac  Opening  of  Stomach  (iamJcr/) 175 

45.  Exposure  of  Cardia  and  Esophagus  {Lambert) 176 

46.  Hour-Glass  Stomach  from  Carcinoma 180 

47.  Hour-Glass  Stomach  from  Ulcer  with  Adhesions iSi 

48.  Double  Anterior  Gastrojejunostomy  in  -Y  for  Trifid  Stomach 185 

49.  Cylindrical  Gastrectomy  or  Sleeve  Resection 186 

50.  Circular  Gastrorrhap'hy  after  Cylindrical  Gastrectomy 186 

51.  Duodenal  Ulcer,  Acute ' 190 

52.  Microphotograph  of  Duodenal  Ulcer 191 

53.  Duodeno-Pyloric  Ulcer  {Jefferson) 192 

54.  ^Microphotograph  of  Duodenal  Ulcer  shown  in  Fig.  55 196 

5-,.  Duodenal  Ulcer,  Cicatrizing 198 

56.  Hour-Glass  Duodenum  from  Cicatrizing  Ulcer,  complicated  by  an  Ulcer  on  the 

Lesser  Curvature  of  the  Stomach      202 

57.  Hour-Glass  Duodenum  from  Cicatrized  Ulcer  adherent  to  the  Pancreas  ....  203 

58.  Fibroma  of  Posterior  \\'all  of  Stomach 206 

59.  Polypus  of  Stomach  near  Pylorus  {Bennett) 210 

60.  Gastric  Polj-pus  near  Pylorus  acting  as  Ball- valve  (Benne/O 210 

61.  Plastic  Linitis  of  the  Stomach 219 

62.  Wiesinger's  Case  of  Volvulus  of  the  Stomach 231 

63.  Skiagraph  of  Eventration  of  the  Diaphragm  {Wood) 23s 

64.  Skiagraph  of  Eventration  of  the  Diaphragm  {Wood) 236 

65.  Microphotograph  showing  Carcinoma  beginning  in  Edge  of  Gastric  Ulcer   .    .    .  246 

66.  Microphotograph  (High  Power)  of  Fig.  65 247 

67.  Carcinoma  of  Stomach,  Specimen  Removed  by  Partial  Gastrectomy  "...        .  250 

68.  Specimen  shown  in  Fig.  67,  opened  along  lesser  curvature 251 

69.  Carcinoma  of  Stomach,  Specimen  Removed  by  Subtotal  Gastrectomy 252 

70.  Specimen  shown  in  Fig.  69  opened  along  Greater  Curvature 253 

71.  Diagram  to  show  Overlapping  of  Anterior  Gastric  Wall  by  Surrounding  Struc- 

tures   289 

72.  Diagram  to  Show  Relations  of  Posterior  Gastric  Wall  to  Surrounding  Structures    290 

73.  Diagram  made  by  Superimposing  Fig.  72  on  Fig.  71 290 

74.  Diagram  of  .\lbert  and  Lembert  Intestinal  Sutures 312 

75.  Beginning  the  Interrupted  Sero-serous  Suture  (Lembert's  Suture) 312 

76.  Continuous  Sero-serous  Suture  (Dupuytren's  Suture) 312 

77.  Subsequent  Steps  of  the  Continuous  Sero-serous  Suture 313 

78.  Fi.xing  the  End  of  the  Continuous  Sero-serous  Suture 313 

79.  Commencing  a  Xew  Continuous  Sero-serous  Suture  by  tying  it  to  the  end  of  the 

Previous  Stitch 313 

80.  Interrupted  Sero-serous  Suture  of  the  Mattress  Type      313 

81.  Continuous  Sero-serous  Suture  of  the  Mattress  Tj^ie 313 

82.  Continuous  Right-angled  Sero-serous  Suture  of  Heyward  Cushing 313 

83.  Closing  the  Parietal  Peritoneum 314 

84.  Method  of  Inserting  "Splint  Sutures"  of  Silkwormgut,  in  Repair  of  the  Abdomi- 

nal Incision 315 

85.  Suturing  the  Anterior  Sheath  of  the  Rectus  Muscle      31S 


LIST    OF    ILLUSTRATIONS  XV 

Figure  Page 

86.  Tying  the  Splint  Sutures 316 

87.  Witzel's  Gastrostomy:  Suturing  Catlieter  in  Stomach 319 

88.  Witzel's  Gastrostomy:  closing  the  Abdominal  Incision 319 

8g.  Stamm's  Gastrostomy 321 

90.  Jianu's  Esophagoplasty 325 

91.  Finney's  Pyloroplasty:  Traction  Sutures  Inserted 327 

92.  Finney's  Pyloroplasty:  Posterior  Continuous  Sero-serous  Suture 327 

93.  Finney's  Pyloroplasty:  Mattress  Sutures  Inserted 328 

94.  Finne3''s  Pyloroplasty:  Opening  the  Stomach  and  Duodenum 329 

95.  Finney's  Pyloroplasty:  Suture  of  Adjacent  Margins  of  the  Stomach  and  Duode- 

num     330 

96.  Finney's  Pyloroplasty:  The  Operation  Completed 331 

97.  Diagram  of  Posterior  "no-loop"  Gastrojejunostomy  in  Sagittal  Section  ....   332 

98.  Posterior  Transmeso  Colic  Gastrojejunostomy:  The  Stomach  E.xposed  through 

the  Transverse  Mesocolon 33S 

99.  Gastrojejunostomy:  First    Sero-serous  Suture  Applied 337 

00.  Gastrojejunostomy:  Viscera  Opened,  Through-and-through  Suture  commenced.   338 

01.  Gastrojejunostomy:  Through-and-through  Suture,  continued 339 

02.  Gastrojejunostomy:  The  .Anastomosis  Completed 340 

03.  Diagram  of  Posterior  "no-loop"  Gastrojejunostomy  seen  from  the  Front    .    .    .   341 

04.  Anterior  .Ante-colic  Gastrojejunostomy  by  Means  of  the  Murphy  Button    .    .    .   342 

05.  Diagram  of  Rou.x's  Method  of  Posterior  Gastrojejunostomy  in -Y 344 

06.  Gastroplasty 345 

07.  Gastro-gastrostomy 346 

08.  Gastro-anastomosis      346 

09.  Gastroplication 346 

to.  Gastroplication,  seen  in  Sagittal  Section 346 

11.  Diagram  Showing  Various  Lines  for  Dividing  the  Stomach  in  Gastrectomy  .  348 

12.  Diagram  of  Subtotal  Gastrectomy 348 

13.  Diagram  of  Billroth's  First  Method  of  Partial  Gastrectomy 349 

14.  Diagram  of  Kocher's  Method  of  Partial  Gastrectomy 351 

15.  Partial    Gastrectomy:  Division   of   the   Gastro-hepatic   and   the    Gastro-colic 

Omenta      354 

16.  Partial  Gastrectomy:  Division  of  the  Duodenum      355 

17.  Partial  Gastrectomy:  The  Stomach  has  been  Removed 356 

18.  Partial  Gastrectomy:  Closure  of  the  Cardiac  Stump 337 

19.  Polya's  Method  of  Gastrectomy 358 

20.  Cylindrical  Gastrectomy:  Clamps  in  Place 361 

21.  Cylindrical  Gastrectomy:  Circular  Gastrorrhaphy 362 

22.  Cylindrical  Gastrectomy:  Circular  Gastrorrhaphy  continued 362 

23.  Cylindrical  Gastrectomy:  Operation  Completed 363 

24.  Transgastric  E.xcision  of  an  Ulcer  on  the  Posterior  Wall  of  the  Stomach      .    .    .  365 

25.  Jejunostomy  by  the  Method  of  Karewski 369 

26.  Jejunostomy  in  -Y  by  the  Method  of  Maydl 370 

27.  Diagram  to  Show  Course  of  Gastric  and  Duodenal   Contents  after  long-loop 

Gastrojejunostomy  with  Entero-anastomosis      381 

28.  Gastro-jejunal  Ulcer  following  Posterior  "no-loop"  Gastro-jejunostomy  .    .    .    .   394 

29.  Specimen  Secured  by  Partial  Gastrectomy  in  a  Case  in  which  a  Marginal  Ulcer 

Developed  9  years  after  Gastro-gastrostomy  for  Hour-glass  Stomach  .    .    .  395 

30.  Another  View  of  Specimen  Shown  in  Fig.  129 395 

31.  Internal  Hernia  after  Gastrojejunostomy  {Mosclicomtz)      396 

32.  Mass  of  Gall-stones  Conglomerated  into  Shape  of  the  Gall-bladder 424 

a.  Radial  Cholesterin  Gall-stone:  Spontaneous  Fracture  iAshhiirsl) 429 


XVI  LIST    OF    ILLUSTRATIONS 

Figure  Page 

134.  Gall-stone  shown  in  Fig.  133  after  Fragments  have  been  Glued  together     .    ,    .  426 

135.  Typhoid  Perforation  of  the  Gall-bladder 430 

136.  Hour-glass  Gall-bladder 444 

137.  Hydrops  of  the  Gall-bladder      450 

13S.  Gall-bladder  deformed  by  Peri-cholecystic  Adhesions 4&0 

139.  Diagram  to  Show  Various  Sites  of  Biliary  Calculi 470 

140.  Extreme  Contraction  of  the  Gall-bladder 474 

141.  Palpation  of  the  Gall-bladder 488 

142.  Bimanual  Palpation  of  the  Gall-bladder      489 

143.  Diagram  to  Show  Parts  which  must  be  Excised  in  a  Case  of  Stricture  at  the 

Hepatico-cystic  Juncture 508 

144.  Resection  of  Choledochus,  Closure  of  both  Ends,  and  Cholecysto-duodenostomy 

(.Kehr) 508 

145.  Resection   of    Choledochus   and    Its    Reunion    over   a    T-tube    {Ginsburg   and 

Specse) 510 

146.  Choledocho-enterostomy  by  Suture  (G/Ms6i(rg  and  Speese) 51  r 

147.  Choledochoplasty  by  Duodenal  flap  (G/Hs6»rf  and  Speese) 512 

148.  Choledochoplasty  by  Means  of  a  Free  Transplant  of  Fascia  Lata  {Ginshiirg-and 

Specse) 513 

149.  Diagram  of  Hepato-cholangeio-enterostoray  (Kehr)      514 

150.  Voelcker's  Method  of  Hepatico-duodenostomy 516 

151.  Sullivan's  Method  of  Hepatico-duodenostomy 517 

152.  Kehr's  Case  of  Aneurysm  of  the  Hepatic  Arterj- 523 

153.  Corset-Liver      535 

154.  Quenu's  ilethod  of  Formolization  of  Hydatid  Cysts  (Ashlinrsl)         569 

155.  Carcinoma  of  the  Gall-bladder 586 

156.  Rupture  of  the  Liver 597 

157.  Stab-wounds  of  the  Liver 606 

158.  Pancreatic  Calculi 622 

159.  Diagram  to  Explain  the  Modern  Theory  of  Diabetes  (uon  A''oor(/<;n) 625 

160.  Wide  Opening  of  the  Gastrocolic  Omentum  to  Expose  the  Pancreas 651 

161.  L5-mphnodes  of  the  Bile-ducts  and  Head  of  the  Pancreas 663 

162.  Specimen  of  Pancreas  and  Duodenum  Removed  at  Autopsy 666 

163.  The  "pancreatic  point"  of  Desjardins,  and  the  " pancreatico-hepatic  area"  of 

Chauffard  and  Rivet 677 

164.  Exposure  of  the  Head  of  the  Pancreas  and  Common  Bile-duct  after  Mobilization 

of  the  Duodenum  (Guibe)      683 

165.  Pancreatostomy  {Link) 688 

166.  Obstructive  Jaundice,  from  Carcinoma  of  the  Pancreas 69s 

167.  Cyst  of  Pancreas  Presenting  beneath  Gastro-colic  Omentum 711 

168.  Cyst  of  Pancreas  Presenting  beneath  Gastro-hepatic  Omentum 711 

169.  Cyst  of  Pancreas  growing  into  Transverse  Meso-colon 712 

170.  Cyst  of  Pancreas  Removed  Entire 715 

171.  Splenomegaly  in  Childhood  (Ashlmrsl) 748 

172.  Patient  in  Elliot's  Position  for  Bile-duct  Operations 760 

173.  Mayo  Robson's  Incision  {Ashlmrsl) 762 

174.  Rotation  of  the  Liver  to  Expose  the  Gall-bladder  and  Bile-ducts 765 

175.  Cholecystostomy:  Drainage  by  Rubber  Tube  in  Gall-bladder 770 

176.  Cholecystostomy:  Cigarette  drain  protecting  Rubber  tube  in  Gall-bladder     .    .  771 

177.  Cholecystostomj';  Fundus  of  Gall-bladder  Sutured  to  Parietal  Peritoneum  to 

Secure  Prolonged  Drainage 772 

178.  Cholecystostomy:  Fundus  of  Gall-bladder  Sutured  to  Anterior  Sheath  of  Rectus 

to  Secure  very  Prolonged  Drainage      772 


LIST    OF    ILLUSTKATIONS  XVll 

Figure  Page 

179.  Cholecystectomy:  The  Cystic  Artery  and  the  Ducts  Exposed 774 

180.  Cholecystectomy;  Repair  of  the  Bed  of  the  Gall-bladder 775 

181.  Transduodenal  Choledochotomy 783 

182.  Retroduodenal  Choledochotomy  (a) 785 

183.  Retroduodenal  Choledochotomy  (b) 786 

184.  Retroduodenal  Choledochotomy  (c) 787 

185.  Retroduodenal  Cholectochotomy  (d) 783 

186.  Cholecysto-duodenostomy      789 

187.  Diagram  of  Transpleural  Hepatotomy  for  Abscess  of  Liver 791 

188.  Transpleural  Hepatotomy:  The  Rib  Excised      792 

189.  Transpleural  Hepatotomy:  Diaphragm  Exposed 792 

190.  Freeman's  Method  of  Resection  of  the  Liver 794 

191.  Suture  of  Liver  after  Resection 795 

192.  Incision  for  Total  Cephalic  Pancreatectomy  (Dcsjardins) 796 

193.  Pancreato-enterostomy  (Coffey) 797 

194.  Pancreato-enterostomy  (Coffey) -  •    ■    ■  798 

19s.  Splenectomy:  Exposure  of  the  Pedicle  through  the  Gastro-splenic  Ligament  .    .  800 

196.  Diagram  of  Structures  in  Splenic  Pedicle 801 

197.  Exposure  of  Splenic  Artery  through  Gastro-hepatic  Ligament 802 

198.  Splenectomy:  Pedicle  Exposed  by  Rotating  Spleen  to  Patient's  Right 803 

PLATES 

I.  Gastric  Ulcer 70 

II.  Duodenal  Ulcer 198 

III.  Carcinoma  of  Stomach      254 

IV.  Endothelioma  Springing  from  Pylorus 282 

V.  Specimen  Secured  by  Cholecystectomy 426 

VI.  Gall-bladder  Removed  for  Acute  Calculous  Cholecystitis 466 

VII.  Suppurative  Cholangeitis  with  Multiple  Abscess  of  Liver      .    .    . 548 

VIII.  Gall-bladder  Removed  for  Cholelithiasis 584 

IX.  Slough  of  Pancreas  Discharged  through  Drainage  Tract  in  left  Loin,  in  a  Case  of 

Acute  Pancreatitis 640 


SURGERY  OF  THE  UPPER  ABDOMEN 


CHAPTER  I 
ANATOMY 


Systematic  descriptions  of  anatomy  are  sought  in  treatises  specially 
devoted  to  the  subject;  and  what  a  reader  desires  to  find  in  a  work 
like  the  present  is  the  surgical  or  applied  anatomy  of  the  parts  under 
discussion.  The  histological  structure  of  the  various  organs  is  there- 
fore omitted,  together  with  a  detailed  statement  of  their  size,  shape, 
and  minute  relations  to  other  structures.  It  has  seemed  wise,  more- 
over, to  consider  the  subject  of  the  anatomy  of  the  upper  abdomen  as  a 
whole,  and  not  to  preface  the  surgery  of  each  organ  with  a  brief  anatom- 
ical outline  in  which  there  would  be  many  repetitions  required. 

The  Abdominal  Wall. — To  the  operating  surgeon  the  abdominal 
wall  should  present  itself  as  a  muscular  and  aponeurotic  structure 
whose  subsequent  strength  depends  upon  the  skill  and  judgment  with 
which  it  is  divided  and  sutured  during  an  operation.  The  abdominal 
muscles,  like  muscles  elsewhere  in  the  body,  are  supplied  with  arteries, 
veins  and  nerves;  and  the  incision  through  these  muscles  should  be 
made  with  due  regard  for  their  preservation,  especially  for  preservation 
of  the  nerves,  since  injury  to  the  latter  is  permanent  and  irreparable. 

The  rectus  muscle  is  attached  at  the  costal  margin  as  far  outward 
as  the  ninth  costal  cartilage.  In  its  upper-two-thirds  the  rectus  muscle 
is  about  8  cm.  broad,  being  somewhat  narrower  as  it  approaches 
the  pubic  spine.  In  the  cadaver  the  muscle  is  usually  less  broad  than 
during  life,  often  measuring  less  than  5  cm.  in  width.  Outside 
of  the  semilunar  line  the  incisian  should  be  transverse,  and  more  or 
less  oblique;  the  fibres  of  the  lateral  muscles  of  the  abdomen  do  not  all 
run  in  the  same  direction,  and  any  simple  incision  must  divide  one  of 
the  muscular  planes  obliquely.  Yet  after  transverse  division  of  any 
muscle,  accurate  suture  will  restore  almost  its  pristine  integrity,  so 
long  as  its  nerve  supply  has  been  preserved.  Transverse  division  even 
of  the  rectus  muscle,  though  undesirable,  results,  after  careful  suture, 
merely  in  adding  one  more  linea  transversa  to  its  structure. 

The  chief  artery  met  with  in  the  upper  abdominal  wall  is  the  in- 


2  ANATOMY 

ternal  mammary  or  some  of  its  terminal  branches.  It  runs  between 
the  rectus  muscle  and  its  posterior  sheath,  and  the  larger  branches  are 
toward  the  middle  line  of  the  body.  The  lower  intercostal  nerves 
run  forward  transversely  between  the  internal  oblicjue  and  transversalis 
muscles  (Fig.   i),  pierce   the  posterior  sheath   of   the   rectus   muscle 


Pig.  I. — Dissection  of  the  Right  Half  of  an  Abdominal  Wall.  The  E.xternal  and 
Internal  Oblique  Muscles  Have  Been  Turned  to  the  Left.  Exposing  the  Lower  Inter- 
costal Nerves  and  the  Deep  Circumflex  Iliac  Artery,  as  They  Lie  upon  the  Transver- 
salis. From  a  Dissection  by  the  Junior  Author  in  the  Laboratory  of  Operative  Surgery 
in  the  University  of  Pennsylvania. 

(the  deep  lamella  of  the  aponeurosis  of  the  internal  oblique),  and 
enter  the  rectus  muscle  from  its  deep  surface  (Fig.  2).  They  will 
be  cut  by  an  incision  parallel  to  the  fibres  of  the  rectus,  unless  this 


ABDOMINAL   WALL 


incision  is  made  close  to  the  linea  alba;    and    loss  of   contractility 
and  atrophy  of  the  part  of  the  muscle  so  affected  follows  such  injury; 
but  as  a  rule  the  impairment  of  function  in  the  epigastric  region  is 
less  serious  than  in  the  hypo- 
gastric region. 

The  distribution  of  the 
lower  intercostal  nerves  is 
important  in  connection  with 
cutaneous  hyperesthesia, 
muscular  rigidity,  and  re- 
ferred pain — all  conditions 
frequently  encountered  in 
abdominal  affections.  The 
sixth  and  seventh  nerves 
supply  the  skin  m  the  epi- 
gastric region  (the  "pit  of 
the  stomach");  the  eighth 
and  ninth,  that  region  be- 
tween the  epigastrium  and 
the  umbilicus;  and  the  tenth, 
the  umbilical  area.  The  cu- 
taneous hyperesthesia,  re- 
ferred pain,  and  muscular 
rigidity  of  the  abdominal 
wall  are  due,  as  is  well 
known,  to  the  overflow  of 
the  stimulation  received  by 
the  cells  in  the  spinal  cord 
from  the  diseased  area  within 
the  abdomen.  When  the 
stimulation  overflows  into 
sensory  nerve  filaments,  cu- 
taneous hyperesthesia  and 
pain  are  produced;  but  the 
motor  nerves  are  usually 
affected  also,  and  hence  mus- 
cular rigidity  of  the  overlying 
abdominal  wall  is  produced 
(viscero-muscular  reflex  of  Mackenzie),  by  the  same  mechanism  as  that 
by  which,  aswas  long  ago  pointed  out  by  Hilton, an  inflamed  joint  isheld 
rigid  by  its  enveloping  muscles.     As  the  flat  muscles  of  the  abdominal 


Fig.  ^  —  The  Si.x  Lower  Intercostal  Nerves  and 
the  First  Lumbar  Nerve  Entering  the  Rectus 
Muscle  from  its  Deep  Surface.  The  Rectus  Muscle 
Has  Been  Drawn  from  Its  Sheath  and  Turned 
toward  the  Left.  From  a  Dissection  by  the 
Junior  Author  in  the  Laboratory  of  Operative 
Surgery  in  the  University  of  Pennsylvania. 


4  ANATOMY 

wall  are  not  innervated  by  a  single  nerve  trunk,  but  by  numerous  twigs 
from  different  nerve  trunks,  where  the  viscero-muscular  reflex  is  re- 
ferred along  one  trunk  only,  merely  a  portion  of  the  muscle  will  contract. 
This  is  not  so  important  in  the  upper  abdomen  as  in  the  iliac  region, 
where  such  band  like  rigidity  has  been  mistaken  for  a  palpably  enlarged 
appendix. 

The  pain  referred  to  the  left  shoulder  blade  in  disease  of  the  duo- 
denum and  stomach  is  to  be  e.xplained  by  the  connection  between 
the  pneumagastric  nerves  and  the  sympathetic  ganglia  on  the  left  side. 
Mayo  Robson  and  Moynihan  have  pointed  out  that  as  long  as  the  gall- 
bladder only  is  involved,  the  referred  pain  is  felt  in  the  right  infra- 
scapular  region,  but  as  soon  as  the  inflammation  or  adhesions  involve 
the  pylorus,  the  pain  is  felt  also  in  the  left  infrascapular  region.  Pain 
may  be  referred  to  the  neck  from  involvement  of  the  phrenic  ner\'e, 
and  to  the  shoulder  tip  through  its  connection  with  the  supra-acromial 
nerve  (p.  26). 

Running  from  the  umbilicus  upward,  along  the  deep  surface  of  the 
right  rectus  muscle,  to  the  longitudinal  fissure  of  the  liver,  is  the  falci- 
form or  suspensory  ligament  of  this  organ,  containing  between  its 
layers  the  round  ligament  or  obliterated  umbihcal  vein  of  the  fetus; 
as  well  as  some  small  veins  from  the  epigastric  vein,  anastomosing  with 
the  portal  system;  some  arterial  twigs  from  the  phrenic  arteries;  be- 
sides lymphatics  and  nerves.  It  is  advisable,  therefore,  it  this  fold  of 
peritoneum  must  be  divided  when  making  incisions  through  the  ab- 
dominal wall  to  be  careful  that  no  oozing  of  blood  goes  undetected. 
The  suspensory  ligament  Hes  rather  close  to  the  ILnea  alba,  and  hence 
an  incision  through  the  outer  half  of  the  right  rectus  muscle  will  not 
injure  it;  if  an  incision  just  to  the  right  of  the  linea  alba  is  to  be  extended 
past  the  umbilicus,  care  should  always  be  taken  to  check  any  bleeding 
from  the  structures  in  thef"  round  ligament  of  the  Hver. 

Surface  Anatomy. — The  umbilicus  is  at  the  level  of  the  third 
lumbar  vertebra.  Approximately  between  it  and  the  spinal  column 
lies  the  third  or  transverse  portion  of  the  duodenum.  Cephalad  to  the 
umbilicus  in  the  recumbent  patient  lies  the  transverse  colon,  about  three 
fingerbreadths  wide,  and  between  this  and  the  ensiform  cartilage  are 
found  the  pyloric  portion  of  the  stomach,  and,  overlapping  this,  the 
left  lobe  of  the  liver.  The  longitudinal  fissure  of  the  liver,  separating 
the  left  from  the  right  lobe,  is  less  than  2.5  cm.  to  the  right  of  the  median 
line  of  the  body.  If  the  transverse  colon  sag,  and  hang  below  the  um- 
bilicus, some  coils  of  small  intestine  may  present  themselves  between 
the  colon  and  the  stomach,  displacing  the  transverse  mesocolon,  which, 


SURFACE    ANATOMY  5 

as  well  as  the  gastro-colic  omentum,  will  be  found  interposed  between 
these  displaced  intestines  and  the  anterior  abdominal  wall. 

The  central  tendon  of  the  diaphragm  is  found  at  the  base  of  the 
ensiform  process  of  the  sternum,  at  the  level  of  the  cartilage  of 
the  sixth  or  seventh  rib,  and  opposite  the  eighth  dorsal  vertebra.  The 
lateral  arches  of  the  diaphragm  rise  and  fall  slightly  during  respiration, 
the  right  being  slightly  higher  than  the  central  tendon,  and  about 
2  cm.  higher  than  the  left  arch. 

The  liver  fills  the  right  hypochondriac  region,  and  extends  through 
the  epigastrium  to  the  left  hypochondriac  region  to  a  distance  of  from 

2  to  4  cm.  beyond  the  left  border  of  the  sternum.  It  may  reach  the 
left  mammary  line.  The  liver  extends  as  high  as  a  transverse  Hne 
drawn  through  the  lower  end  of  the  gladiolus  (the  mesosternum),  or 
the  base  of  the  ensiform  cartilage.  The  upper  surface  of  the  left  lobe 
is  on  this  same  level  (the  fifth  intercostal  space) ;  but  the  right  lobe 
is  a  trifle  higher  and  is  said  to  reach  the  lower  border  of  the  fifth  rib. 
Since  the  position  of  the  liver  varies  slightly  with  that  of  the  body, 
and  with  the  movements  of  the  diaphragm,  these  outlines  are  only 
approximately  correct.  The  lower  surface  of  the  right  lobe  of  the 
liver  posteriorly  is  opposite  the  spine  oi  the  eleventh  dorsal  vertebra, 
and  in  the  midaxillary  line  is  at  the  costal  margin;  between  the  mid- 
axillary  line  and  the  right  semilunar  line  the  thin  anterior  margin  of 
the  liver  projects  about  2  cm.  below  the  costal  margin,  and  crosses 
the  median  line  of  the  body  in  a  line  drawn  from  the  ninth  right,  to  the 
eighth  left,  costal  cartilage.  The  gall-bladder  lies  beneath  the  ninth 
right  costal  cartilage  in  the  semilunar  line,  at  the  outer  border  of  the 
right  rectus  muscle. 

The  relations  of  the  stomach  vary  considerably.  When  distended, 
it  is  in  contact  with  the  anterior  abdominal  wall  in  a  triangle  bounded 
by  the  anterior  margin  of  the  liver,  the  left  ninth  and  tenth  costal 
cartilages,  and  a  line  drawn  between  the  tenth  costal  cartilages.  The 
cardiac  orifice  of  the  stomach  is  opposite  a  point  2.5  cm.  to  the  left 
of  the  seventh  left  chondro-sternal  junction,  at  the  level  of  the  eleventh 
thoracic  vertebra;  the  pyloric  orifice  Hes  beneath  the  liver,   about 

3  cm.  below  the  base  of  the  ensiform  cartilage,  at  the  level  of  the  upper 
edge  of  the  first  lumbar  vertebra;  but  as  the  stomach  becomes  distended 
the  pylorus  approaches  the  right  linea  semilunaris.  The  line  for  the 
lesser  curvature  of  the  stomach  is  drawn  from  the  position  of  the 
cardiac  orifice  to  that  of  the  pylorus.  The  line  for  the  greater  curvature 
extends  upward  and  to  the  left  from  the  position  of  the  cardiac  orifice 
to  the  fifth  rib,  slightly  external  to  the  left  mammary  line,  and  thence 


6  ANATOMY 

to  the  position  of  the  pyloric  orifice.  The  Hne  of  the  greater  curvature 
is  convex  downward  and  to  the  left;  that  of  the  lesser  curvature  is 
nearly  vertical  when  the  stomach  is  empty. 

The  duodenum  is  from  25  to  30  cm.  in  length,  commencing  at  the 
pyloric  orifice  of  the  stomach,  and  ending  in  the  jejunum  at  the  left 
side  of  the  body  of  the  second  lumbar  vertebra,  after  haviarg  described 
a  half  circle  with  its  convexity  downward.  The  first  portion  of  the 
duodenum,  about  5  cm.  long,  passes  from  the  pyloric  end  of  the  stomach 
to  the  right,  upward  and  backward,  to  the  neck  of  the  gall-bladder; 
the  second  portion  is  about  8  cm.  in  length,  and  extends  from  the 
neck  of  the  gall-bladder,  downward  along  the  right  of  the  spinal  column 
to  the  level  of  the  third  lumbar  vertebra.  Here  the  third  portion  of 
the  duodenum  commences,  passing  obliquely  upward  to  the  left, 
across  the  body  ot  the  second  lumbar  vertebra.  A  line  drawn  from 
a  point  8  cm.  to  the  right  of  the  umbilicus,  to  a  point  5  cm.  to  the  left 
and  aboA-e  it,  will  nearly  indicate  the  position  of  the  third  portion. 
The  fourth  portion  is  only  about  2  cm.  in  length;  it  passes  upward 
from  the  termination  of  the  third  portion,  and  becomes  continuous 
with  the  jejunum  at  the  origin  of  the  mesentery. 

The  pancreas  extends  across  the  bodies  of  the  first  and  second 
lumbar  vertebras  from  the  hilum  of  the  spleen  in  the  left  hypochondriac 
region,  to  the  second  portion  of  the  duodenum  in  the  epigastric  region. 
Its  length  is  from  15  to  20  cm.,  and  its  largest  portion,  called  the 
head,  is  surrounded  by  the  semicircle  of  the  duodenum  as  a  picture  is 
surrounded  by  its  frame;  while  its  body  crosses  the  spinal  column, 
and  its  tail  is  in  contact  with  the  spleen.  It  lies  between  the  celiac 
axis,  above,  and  the  superior  mesenteric  vessels,  below,  these  latter 
separating  it  from  the  transverse  (third)  portion  of  the  duodenum. 

The  spleen  extends  in  the  mid-axillary  line  longitudinally  from 
the  ninth  to  the  eleventh  rib,  and  transversely  from  the  midaxillary 
to  the  posterior  axillary  line.  Its  long  axis  is  nearly  parallel  to  the 
course  of  the  ribs. 

Embryology. — To  understand  the  various  folds  and  recesses  of 
the  peritoneum  in  the  upper  abdomen  it  is  essential  to  revert  to  the 
embryonal  stage  before  this  membrane  has  developed  the  perplexing 
conditions  found  in  adult  life.  For  practical  purposes  it  is  sufficient  to 
describe  the  fetal  state  as  follows:  The  peritoneum  is  to  be  regarded 
as  a  closed  sac  filling  the  abdominal  cavitj';  along  the  posterior  part 
of  the  abdominal  cavity,  back  of  this  closed  sac  and  parallel  with  the 
spinal  column,  runs  the  digestive  tract  in  the  form  of  a  long  straight 
tube.     At  first  this  tube  is  in  connection  with  the  region  outside  of  the 


EMBRYOLOGY 


abdominal  cavity  by  means  of  a  prolongation  through  the  navel, 
known  as  the  vitelline  duct.  This  duct  later  becomes  detached  from 
the  navel,  but  is  sometimes  still  evident  in  adult  hfe  as  Meckel's 
diverticulum.  While  still  attached  to  the  umbilicus  it  acts  as  a  guj^ 
rope,  and  pulls  the  formerly  straight  intestinal  canal  forward  in  a 
U-shaped  projection,  the  arms  of  the  U  being  known  as  the  upper  and 
lower  (Fig.  3).     When  the  intestinal  tube  is  thus  pulled  forward,  the 


Stnmach 


Offiphalo-yia 
enlni(  c/uct. 

U/Y/r/luS. 


Hypogaitnr  Art. 


ladder 


cctu/n 


Fig.  3. — Diagram  of  Early  Stage  of  Development.  The  Portions  of  the  Parietal 
Peritoneum  not  Drawn  Away  from  the  Body  Walls  to  Form  Mesenteries,  Ligaments, 
etc.,  are  Indicated  by  Deeper  Shading. 

closed  peritoneal  sac  is  pushed  in  front  of  it  by  the  intestine,  which 
becomes  more  or  less  completely  covered  by  the  peritoneum,  still 
retaining,  however,  an  extraperitoneal  surface  through  which  it  receives 
its  blood  vessels,  nerves  and  lymphatics.  The  two  folds  of  peritoneum 
covering  these  structures,  as  they  pass  to  the  intestinal  tube,  are  known 
as  the  mesentery.     The  upper  part  of  the  primitive  intestinal  tube, 


8 


ANATOMY 


Post  Wall 


Dorsal 
Mestnteri/ 


Pancreas 


close  beneath  the  diaphragm,  becomes  dilated,  and  forms  the  stomach 
at  first  it  lies  longitudinally  in  the  abdominal  cavity,  and  somewhat 
resembles  the  bulb  of  a  hand  syringe  in  its  relation  to  the  rest  of  the 
tube.  Its  greater  curvature  lies  posterior,  and  the  pylorus  is  its 
lowest  part.  That  portion  of  the  primitive  intestinal  tube  just  below 
the  stomach  forms  the  duodenum,  and  from  its  anterior  wall  the  liver 
grows  out,  as  a  compound  tubular  gland.  The  rapid  growth  of  the 
liver,  and  its  position  close  beneath  the  diaphragm,  account  in  large 
measure  for  the  peculiar  distributions  of  the  peritoneum  around  it. 
It  develops  from  the  anterior  surface  of  the  duodenum,  and  grows 
forward,  pushing  the  peritoneum  in  front  of  it  and  downward,  leaving 
a  pedicle  of  peritoneum  only  at  its  origin  from  the  duodenum  and 
along  its  inferior  surface,  lying,  so  to  speak,  above  the  closed  peritoneal 

sac,  between  this  membrane  and 
thediaphragm.  From  the  umbilicus 
there  passes  upward  outside  the 
anterior  wall  of  the  closed  peri- 
toneal sac,  a  vein,  known  as  the 
umbilical  vein,  which  persists  in  the 
adult  as  the  round  ligament  of  the 
liver,  and  which  is  enveloped  by 
two  folds  of  peritoneum  known  as 
the  falciform  or  suspensory  liga- 
ment of  the  liver.  The  urachus 
and  the  hypogastric  arteries  raise 
similar  folds  of  peritoneum  below 
the  umbilicus.  The  round  liga-. 
ment  passes  to  the  longitudinal 
fissure  of  the  liver,  and  when  it 
reaches  the  transverse  fissure 
blends  with  the  portal  vein,  into  which  vessel  it  emptied  its  blood 
during  intrauterine  life. 

The  duodenum  at  this  period  of  development  has  already  a  mesen- 
terj^  of  its  own,  slight  in  extent,  lying  between  it  and  the  posterior 
abdominal  wall,  and  of  course  continuous  above  with  the  gastric 
mesentery  and  below  with  that  of  the  jejunum.  Into  the  layers  of 
this  duodenal  mesentery  the  pancreas  grows,  extending  backward 
from  the  duodenum,  just  as  the  liver  grows  forward  (Fig.  4). 

Now  commences  a  complex  process  of  rotation  of  all  the  abdominal 
viscera.  The  lower  limb  of  the  U-shaped  intestinal  tube,  in  which  the 
cecum  begins  to  bud,  rotates  upward  in  front  of  and  above  the  upper 


Klci.for/n. 
AntWall 


Pig.    4. — Diagram    Showing    Relation    of 
Duodenum  to  Liver  and  Pancreas. 


EMBRYOL(')GY  9 

limb,  and  the  cecal  portion  passes  first  through  the  umbilical  region  to 
the  left  hypochondriac  region,  thence  to  the  right  hypochondrium,  and 
finally  at  birth  settles  down  toward  the  right  iliac  region  of  the  ab- 
domen. This  rotation  of  the  intestine  takes  place  from  left  to  right 
around  the  superior  mesenteric  artery  as  an  axis  in  such  a  manner 
that  the  colon  crosses  the  commencement  of  the  small  intestine  trans- 
versely.    While  in  this  way  the  commencement  of  the  large  intestine 


Aorta 


CoeliacAxis 


Bile  duct. 


Duodenum 


SupJIesenferic  Art. 


Pc 


ancreas 


Caecum 


S.Intestines 


L.  Intestine 


Fig.  5. — Diagram  Representing  Early  Stage  of  Rotation  of  Abdominal  Viscera. 

is  thrown  over  to  the  right  side,  the  small  intestine  for  the  greater 
part  assumes  a  position  on  the  left,  and  the  former  right  side  of  the 
mesentery  becomes  the  left  and  mce  versa  (Fig.  5).  Thus,  the  lower 
part  of  the  duodenum  is  carried  to  the  left  and  the  commencement 
of  the  large  intestine  is  carried  across  it — an  e.xplanation  of  the  position 
of  the  duodenum  behind  the  transverse  colon  in  the  adult,  and  of  the 


10 


ANATOMY 


passage  of  the  superior  mesenteric  artery  over  the  front  of  the  duo- 
denum. The  influence  that  the  rotation  of  the  intestinal  loop  has 
upon  the  mesentery  may  be  readily  appreciated:  the  attachment  of 
the  mesentery  of  the  small  intestine  (the  upper  limb  of  the  U-shaped 
digestive  tube)  remains  practically  unchanged,  while  that  of  the 
large  intestine  assumes  attachments  corresponding  to  the  ascending, 
the  transverse  and  the  descending  mesocolon.  At  the  same  time 
that  this  intestinal  rotation  is  taking  place  from  left  to  right,  the 


Stomac/t 


L.Intesfinf 


Caecum 


Intestines 


Fig.  6. — Diagram  Representing  Later  Stage  of  Rotation  of  Abdominal  Viscera. 

stomach  likewise  undergoes  rotation  in  the  same  direction,  so  that 
its  left  side  becomes  anterior,  and  its  right  side  posterior  in  position. 
The  spleen,  which  from  about  the  fifth  week  of  intrauterine  life  may 
be  distinguished  in  the  dorsal  mesogastrium,  is  carried  to  the  left 
by  the  rotation  of  the  stomach;  and  the  gastro-splenic  ligament  cor- 
responds to  that  portion  of  thedorsalmesogastrium  in  which  it  originally 
developed.  The  liver  passes  to  the  right  hypochondriac  region,  and 
the  pancreas  is  shifted  slightly  to  the  left.     The  pyloric  end  of  the 


EMBRYOLOGY  II 

stomach  ascends,  and  the  greater  curvature  becomes  the  inferior 
border,  while  the  lesser  curvature  becomes  the  superior  border  of  the 
stomach.  The  stomach  has  now  therefore  an  anterior  and  a  posterior 
wall,  both  covered  with  peritoneum;  but  whereas  the  anterior  is  in 
free  communication  with  the  general  cavity  of  the  peritoneum,  the 
posterior  wall  has  become  more  or  less  isolated,  and  is  in  relation  with 
the  pancreas,  the  lesser  peritoneal  cavity  separating  them  (Fig,  6), 
This  lesser  peritoneal  cavity  retains  its  only  connection  with  the 
general  peritoneal  cavity  at  its  right  extremity  through  the  foramen 
of  Winslow.  Above  the  stomach  the  gastro-hepatic  omentum  stretches 
from  its  lesser  curvature  to  the  liver,  while  from  its  greater  curvature 
the  great  omentum  passes  downward  between  the  stomach  and  the 
transverse  colon,  at  first  consisting  of  two  double  folds  of  peritoneum. 
Later  these  double  folds  fuse  and  become  adherent  to  the  transverse 
colon,  so  that  the  adult  type  is  found  shortly  after  birth.  The  duo- 
denum and  the  pancreas  are  by  this  process  of  rotation  sequestered 
behind  the  stomach  and  transverse  colon,  and  being  subject  to  no 
movement  of  any  consequence  lose  their  posterior  mesenteries  by 
absorption,  and  become  in  extrauterine  life  retroperitoneal  organs. 
It  is  a  law  that  when  two  serous  surfaces  are  approximated,  and  little 
or  no  motion  exists  between  them,  they  fuse.  Thus,  the  duodenum 
and  its  mesentery,  in  which  the  outgrowth  of  the  pancreas  develops, 
are  pressed  by  the  transverse  colon  against  the  posterior  abdominal 
wall  and  unite  extensively  with  the  peritoneum  covering  the  latter. 
The  mesentery  of  the  small  intestine,  which  grows  apace  with  the 
gut  at  its  intestinal  attachment,  is  thrown  into  fan-shaped  folds, 
since  at  its  vertebral  attachment  it  remains  short.  The  transverse 
mescolon,  carried  by  the  colon  transversely  across  the  end  of  the 
duodenum,  obtains  secondary  attachment  to  the  latter  and  to  the 
posterior  abdominal  wall,  in  a  line  from  left  to  right,  and  remains 
permanently  as  a  well-marked  mesentery.  Thus,  the  transverse  colon 
with  its  mescolon  divides  the  abdominal  cavity  into  an  upper  part 
that  includes  stomach,  liver,  duodenum  and  pancreas,  and  a  lower 
which  contains  the  small  intestine.  The  mesenteries  of  the  ascending 
and  descending  colon  become  obliterated  by  fusing  with  the  parietal  peri- 
toneum of  the  posterior  abdominal  wall,  so  that  in  the  mature  condition 
these  parts  of  the  gut  are,  as  a  rule,  covered  by  peritoneum  only  in  front 
and  at  the  sides. 

The  development  of  the  great  omentum  begins  in  the  third  month 
of  fetal  life.  Being  originally  the  posterior  mesogastrium,  attached 
at  the  greater  curvature  of  the  stomach,  it  extends  gradually  downward 


12 


ANATOMY 


above  the  transverse  colon.  Coming  in  contact  in  tlie  tirst  part  of 
its  course  witli  the  transverse  mescolon,  the  great  omentum  soon  fuses 
with  this,  and  subsequently  with  the  transverse  colon,  and  this  relation 
becomes  permanent;  their  bloodvessels,  however,  remain  distinct:  the 
gastro-epiploic  arteries  supply  branches  to  the  stomach  and  omentum, 
while  the  transverse  colon  is  supplied  by  the  middle  colic  artery. 
This  provides  relatively  avascular  areas  through  which  the  posterior 
wall  of  the  stomach  may  be  exposed,  by  detaching  the  great  omentum 
from  the  transverse  colon — the  so-called  intercolo-epiploic  rcute 
(Fig.  ii).  The  pancreas,  at  first  situated  between  the  two  layers 
of  the  mesogastrium,  acquires  its  retroperitoneal  position  also  during 
the  third  month. 

Topographical  Anatomy.     Stomach. — We  may  recognize  two  main 
divisions  of  the  stomach,  the  cardiac  and  the  pyloric  portions  (Fig.  7), 


Pyloro- 
douoclena.1 
openinci 

Puloi'ic  antru 

Solcgs  inte 

Py( 

Fit;.    7.  —  Diagrammatic  Outline  of  llic  Stomach. 

which  are  separated  by  the  incisura  angularis,  at  the  point  where  the 
lesser  curvature  at  first  nearly  vertical  changes  its  direction  to  run 
upward  and  backward.  The  uppermost  part  of  the  cardiac  portion 
is  called  the  fundus;  this  Hes  wholly  above  the  level  of  the  cardiac 
orifice.  The  cardial  antrum  is  that  part  of  the  gastric  lumen  which 
corresponds  to  the  abdominal  part  ot  the  esophagus.  The  pyloric 
antrum  is  the  terminal  2.5  cm.  of  the  gastric  canal,  immediately  ad- 
jacent to  the  pylorus;  it  is  limited  toward  the  patient's  left  by  the 
sulcus  intermedins. 

The  musculature  of  the  pyloric  portion  of  the  stomach  is  much 


STOMACH  13 

more  developed  than  is  that  of  the  body  of  the  stomach,  a  fact  which 
is  explained  by  the  motor  functions  of  the  stomach  during  digestion 
(p.  46).  When  tonic  contraction  of  the  pyloric  portion  exists,  it 
may  bear  considerable  resemblance  to  the  outline  of  an  hourglass 
stomach  (Fig.  23).  The  cardiac  orifice  of  the  stomach  is  directed 
almost  horizontally  toward  the  left,  so  that  the  surgeon's  finger, 
seeking  entrance  to  the  esophagus  from  within  the  stomach,  must  be 
passed  toward  the  patient 's  right. 

In  adult  life  the  stomach  is  almost  entirely  intraperitoneal.  It 
retains  its  primitive  mesentery  from  its  greater  curvature  in  the 
form  of  the  gastro-colic  omentum;  while  the  mesentery  acquired  for 
it  by  the  growth  of  the  liver,  attached  to  the  lesser  curvature,  is  known 
as  the  gastro-hepatic  omentum.  The  greater  and  lesser  curvatures 
of  the  stomach  are  thus  extraperitoneal,  and  contain  the  main  blood 
vessels.  Along  the  lesser  curvature  run  from  left  to  right  the  gastric 
or  coronary  artery,  from  the  celiac  axis,  and  from  right  to  left  the 
pyloric  artery,  from  the  hepatic  artery,  itself  a  branch  of  the  cehac 
axis.  Along  the  greater  curvature  of  the  stomach  runs  from  left  to 
right  the  gastro-epiploica  sinistra,  from  the  splenic,  and  from  right 
to  left  the  gastro-epiploica  dextra,  from  the  hepatic  through  the 
gastro-duodenal.  The  anastomosis  of  both  pairs  of  arteries  is  very 
free,  and  when  divided  at  any  part  of  their  course  severe  hemorrhage 
from  both  ends  is  to  be  anticipated.  Smaller  branches  are  given  off 
at  right  angles,  which  run  transversely  across  the  walls  of  the  stomach. 
The  branches  from  the  lesser  curvature  supply  about  two-thirds  of 
the  areas  on  the  anterior  and  posterior  gastric  walls.  The  veins 
correspond  to  the  arteries,  and  ultimately  empty  into  the  portal  vein. 
The  left  gastro-epiploic  usually  is  the  main  source  of  the  blood  supply 
of  the  omentum,  ramifying  on  its  posterior  surface;  while  the  right 
gastro-epiploic  is  distributed  more  to  the  stomach. 

Except  for  these  omental  regions  the  only  extraperitoneal  portion 
of  the  stomach  is  a  small  and  irregular  triangular  area  on  its  posterior 
surface  near  the  cardiac  opening.  One  angle  of  this  triangle  is  at  the 
point  where  the  coronary  artery  reaches  the  stomach  (the  gastro- 
phrenic ligament),  a  second  is  at  the  commencement  of  the  gastro- 
splenic  portion  of  the  great  omentum,  while  the  third  is  to  the  left  of 
and  below  the  cardiac  opening  of  the  stomach. 

The  lymphatics  of  the  stomach  are  of  considerable  importance  in 
connection  with  the  metastasis  of  malignant  growths,  and  have  only 
within  recent  years  received  adequate  attention.  The  stomach  may  be 
divided  roughly  into  three  lymphatic  areas  (Fig.  8) :  one,  in  the  region 


14 


ANATOMY 


Fig.  8.- 


of  the  fundus  of  the  stomach,  where  the  nodes  are  few,  and  two  others, 
along  the  greater  and  lesser  curvatures  respectively  (Cuneo,  1900). 
Of  these  latter  two  areas,  the  nodes  along  the  lesser  curvature  are 
much  more  apt  to  be  involved  in  malignant  growths,  the  area  affected 
extending  as  far  toward  the  esophageal  end  of  the  stomach  as  the 
position  of  the  coronary  artery;  while  the  duodenum  is  rarely  involved 
for  a  distance  of  more  than  two  or  three  centimetres.     The  practical 

deductions  from  these  facts  will  be 
considered  in  greater  detail  when 
discussing  malignant  growths  of 
the  stomach.  From  these  various 
lymphatic  nodes  the  lymph  vessels 
pass  to  the  celiac  nodes;  the  vessels 
from  the  lesser  curvature  following 
the  course  of  the  coronarj^  artery, 
and  those  from  the  greater  curva- 
ture running  with  the  right  gastro- 

-Lvniphatic  Areas  of  the  Stomach. '„^^•  ,      i^     u    4.U    ^    *.  4.. 

■    ^  epiploic  vessels,  both  sets  eventu- 

ally meeting  in  the  same  nodes  (celiac)  around  the  aorta,  above  the 
origin  of  the  superior  mesenteric  artery.  Jamieson  and  Dobson  have 
■  made  a  more  recent  study  of  the  lymphatics  of  the  stomach  (1907). 
They  found  nodes  beneath  the  pylorus  quite  frequently  present,  drain- 
ing the  neighboring  portion  of  the  greater  curvature.  In  not  a  few 
instances  they  were  able  to  trace  lymph  channels  from  the  pylorus 
directly  past  the  lower  coronary  group  of  glands  into  the  right 
suprapancreatic  glands  lying  along  the  trunk,  of  the  hepatic  artery. 

The  stomach  is  supplied  liberally  by  sympathetic  nerves,  as  well  as 
by  the  terminal  filaments  of  the  pneumogastric.  The  left  pneumo- 
gastric  curves  around  to  the  anterior  border  of  the  esophagus,  just 
above  the  cardiac  orifice  of  the  stomach,  and  distributes  branches  to 
the  lesser  curvature  and  anterior  wall  of  the  stomach;  while  the  right 
pneumogastric  is  similarly  distributed  over  the  posterior  wall.  Fila- 
ments from  both  nerves  inosculate  along  the  greater  curvature.  Some 
filaments  from  the  right  nerve  pass  to  the  left  side  of  the  celiac  and 
splenic  plexuses  of  the  sympathetic  system,  while  some  of  the  filaments 
from  the  left  nerve  pass  from  the  lesser  curvature  of  the  stomach 
through  the  gastro-hepatic  omentum  to-  the  hepatic  plexus. 

The  posterior  wall  of  the  stomach  cannot  be  satisfactorily  palpated 
through  the  foramen  of  Winslow;  as  a  rule  only  the  posterior  surface 
of  the  pylorus  is  thus  reached  (Fig.  9).  In  the  free  fold  of  the  gastro- 
hepatic  omentum  may  be  felt  the  common  bile  duct,  furthest  forward, 


STOMACH 


Fig.  o. — Probe   in    Foramen  of  Winslow.      The  Liver  Has  Been  Drawn  Upward  to  Expose 
the  Gastro-hepatic  Omentum. 


Fig    10. — Structures  in  the  Lesser  Peritoneal  Cavity  Exposed  by  Dividing  the  Gastro-colic 

Omentum. 


i6 


ANATOMY 


antl  further  in  ;ind  to  the  patient's  left  the  hepatic  artery,  with  the 
portal  vein  behind  and  between.  The  duct  of  Wirsung  (pancreatic)  is 
too  short  and  too  low  down  to  be  palpated  without  loosening  the  layer  of 
peritoneum  covering  the  right  side  of  the  descending  duodendm.     To 


Fig.  II.  —  Posterior  Gastric  Wall  E.\posed  by  Detaching  Great  Omentum  from 
Transverse  Colon — the  "  Intercolo-epiploic  Route."  The  Stomach  Has  Been  Turned 
Upside  Down  Around  its  Lesser  Curvature  as  a  Hinge.  Freely  Exposing  the  Lesser 
Peritoneal  Cavity. 


Right  gastro-epiploic  artery. 
Gastric  or  coronary  artery. 
Hepatic  artery. 
Gastro-duodenal  artery. 


6.  Middle  colic  artery. 

7.  Celiac  axis;   above  it  the  Spigelian  lobe  of 
the  liver. 
Splenic  artery;  below  it.  the  pancreas. 


3 

4 

5.   Superior  pancreatico-duodenal  artery.  9.  Left  gastro-epiploic  artery. 

From  a  Dissection  by  the  Junior  Author  in  the  Laboratory  of    Operative  Surgery  in 

the  University  of  Pennslyvania. 

expose  thoroughly  the  posterior  wall  of  the  stomach  we  have  a  choice 
of  three  routes — through  the  gastro-hepatic  omentum,  through  the 
gastro-colic  omentum,  or  by  detaching  the  great  omentum  from  the 


LIVER 


17 


transverse  colon,  thus  passing  below  the  great  omentum.  Only  in 
cases  with  marked  ptosis  of  the  stomach  is  adequate  exposure  obtained 
through  the  gastro- hepatic  omentum.  Where,  however,  the  gastro-colic 
omentum  is  sufficiently  wide  to  permit,  this  may  be  divided,  close  to 
the  colon,  so  as  to  avoid  the  gastro-epiploic  arteries;  the  stomach  is 
then  partially  inverted  through  the  opening  (Fig.  10).  But  a  still 
wider  exposure,  with  no  damage  to  any  bloodvessels  of  consequence,  is 
obtainable  through  the  third  route,  namely  by  passing  beneath 
the  great  omentum  and  detaching  it  from  the  transverse  colon  (Fig. 
11).  Access  across  the  transverse  mesocolon,  sufficient  for  the  per- 
formance of  posterior  gastro- jejunostomy,  is  not  sufficient  for  adequate 
exploration. 

Liver. — The  liver  presents  sev- 
eral extraperitoneal  areas.  The 
largest  is  on  the  postero-superior 
surface  of  the  right  lobe,  between 
the  layers  of  the  right  portion  of  the 
coronary  ligament  (Figs .  1 2  and  15). 
Here,  about  the  middle  of  the  pos- 
terior surface  of  the  liver,  the  in- 
ferior vena  cava  is  found.  The 
extra-peritoneal  area  between  the 
layers  of  the  median  and  left  por- 
tions of  the  coronary  ligament  is 
insignificant  in  size,  as  is  also  that 
region  about  the  transverse  fissure 
where  the  bile  duct,  the  portal 
vein  and  the  hepatic  artery  are 
found.  For  practical  purposes, 
therefore,  the  liver  is  wholly  an 
intraperitoneal     organ;     although 

r                      „    •    i*            it.            u      **  Fig.  12. — Diaeram  of  Peritoneal  Reflec- 

abscesses      pomtmg       through      its  ti„„,i„  Median  Sagittal  Section.     Note  the 

superior     surface     are    usually    ex-  Arrow    in    the    Foramen    of  Winslow;    the 

,           .               ,  Stomach  Suspended  from  the  Liver  by  the 

eluded  from  the  general  peritoneal  Oastro-hepatic  Omentum;  and  the  Superior 

cavity  by  adhesions.  Mesenteric  Artery  Emerging  from  theAorta 

-'       ■'  Between  the  Pancreas  and  Duodenum,  and 

When    the   hand   is   introduced  Giving  off  its  First  Large  Branch, the  Middle 

between  the  right  lobe  of  the  liver      °^'^    ^  "^ ' 

and  the  diaphragm  through  an  abdominal  incision,  it  passes  back- 
ward over  the  upper  convex  surface  of  the  liver  for  about  15  cm., 
when  the  finger  tips  are  arrested  by  the  coronary  ligament,  running 
transversely  across  the  surface  of  the  liver.  The  falciform  ligament 
2 


I  a  ANATOMY 

will  be  felt  running  forward  from  the  coronary  ligament,  close  to  the 
median  line  of  the  body,  and  will  prevent  the  fingers  from  passing 
from  the  surface  of  the  right  lobe  across  to  that  of  the  left.  By  carry- 
ing the  hand  well  along  to  the  right  edge  of  the  liver,  the  right  ex- 
tremity of  the  coronary  ligament,  known  as  the  right  lateral  ligament, 
will  be  felt,  and  in  some  cases  the  fingers  can  be  passed  around  the 
free  margin  of  this  ligament  on  to  the  posterior  surface  of  the  liver, 
back  of  the  posterior  layer  of  the  coronary  ligament.  The  hand  is 
here  arrested  by  the  reflection  of  the  visceral  peritoneum  on  to  the 
posterior  abdominal  parietes.  On  the  left  side  of  the  falciform  liga- 
ment, above  the  left  lobe  of  the  liver,  the  left  coronary  ligament,  and 
its  extreme  portion,  the  left  lateral  ligament,  may  likewise  be  palpated 
by  the  examining  hand. 

The  under  surface  of  the  liver  is  also  quite  easily  examined  by  the 
sense  of  touch.  At  the  cartilage  of  the  right  ninth  rib,  about  5  cm. 
to  the  right  of  the  falciform  ligament,  held  close  against  the  under 
surface  of  the  liver  by  a  fold  of  peritoneum,  is  the  gall-bladder,  and 
by  following  this  landmark  backward  with  the  fingers,  we  are  led 
first  to  the  cystic  duct,  then  across  the  anterior  margin  of  the  foramen 
of  Winslow  along  the  common  bile  duct  in  the  free  margin  of  the 
gastro-hepatic  omentum,  to  the  posterior  surface  of  the  duodenum. 
Beyond  this  point  the  bile  duct  usually  cannot  be  palpated,  as  it 
becomes  retroperitoneal  behind  the  descending  part  of  the  duodenum. 
To  the  right  of  the  gall-bladder  the  hand  will  pass  beneath  the  right  lobe 
of  the  liver  and  above  the  transverse  mesocolon  and  the  upper  pole  of 
the  right  kidney,  as  far  as  the  posterior  abdominal  wall  (twelfth  rib) ;  and 
in  some  cases  slightl}'  upward  on  the  posterior  surface  of  the  liver,  before 
meeting  with  the  inferior  reflection  of  peritoneum  which  forms  the  pos- 
terior layer  of  the  right  coronary  ligament.  Close  to  the  spinal  column 
the  ascending  vena  cava  can  be  palpated.  Passing  the  hand  to  the  left 
of  the  gall-bladder,  along  the  inferior  surface  of  the  left  lobe  of  the 
liver,  the  fingers  are  arrested  within  6  or  7  cm.  by  the  attachment  of 
the  gastro-hepatic  omentum  along  the  transverse  fissure  of  the  liver. 
This  fissure  is  limited  on  the  right  by  the  neck  of  the  gall-bladder  and 
the  cystic  duct,  and  on  the  left  by  the  round  ligament  within  the  folds 
of  the  falciform  ligament  attached  to  the  longitudinal  fissure  of  the  liver 
(Fig.  9).  By  now  passing  the  hand  further  to  the  left,  the  left  extremity 
of  the  gastro-hepatic  omentum  is  reached,  enclosing  the  esophagus,  and 
the  hand  can  be  pushed  backward  between  the  cardiac  end  of  the 
stomach  below  and  the  left  lobe  of  the  liver  above  until  the  posterior 
layer  of  the  left  lateral  ligament  is  encountered,  at  the  posterior  surface 


LWER 


19 


of  the  left  lobe  of  the  liver  (Fig.  1 5) .  The  Spigelian  lobe  may  be  palpated 
by  passing  the  finger  through  the  foramen  of  Winslow,  and  then  upward 
between  the  spinal  column  (tenth  and  eleventh  dorsal  vertebra  covered 
by  the  diaphragm)  and  the  liver.  The  surface  of  the  liver  so  reached  is 
the  Spigehanlobe  (Fig.  13).  It  is  wholly  within  the  lesser  peritoneal  sac. 
Its  right  boundary  is  formed  by  the  inferior  vena  cava,  its  left  by  the 
esophagus  and  cardia  of  the  stomach,  its  upper  boundary  by  the  coro- 
nary ligament  of  the  liver,  and  its  lower  by  the  transverse  fissure  of 
the  Uver  (attachment  of  the  gastro-hepatic  omentum).  As  the  finger 
lies  in  the  foramen  of  Winslow  that  portion  of  the  hver  immediately 


Fio.    13. 


-Diagram  of  Peritoneal  Retiections  in  a  Horizontal  Transverse  Section  Pass- 
ing Through  the  Pylorus. 


1.  Body  of  eleventh  thoracic  vertebra. 

2.  Liver. 

3.  Inferior  vena  cava. 

4.  Peritoneal  cavity  (black)  between  right  lobe  of 
liver  and  diaphragm. 

5.  Peritoneum  covering  Spigelian  lobe  of  liver. 

6.  Margin  of  right  lung. 


7.  Pleural  cavity  (blue). 

8.  Ensiform  process  of  sternum. 

9.  Heart. 

10.  Great  Omentum. 

11.  Stomach. 

12.  Spleen. 

13.  Aorta. 


above  it  is  the  caudate  lobe,  connecting  the  Spigelian  to  the  right  lobe; 
the  hepatic  artery  lies  below  the  finger,  being  on  its  way  from  the 
cehac  axis  to  the  gastro-hepatic  omentum ;  and  the  vena  cava  lies  between 
the  finger  and  the 'vertebral  column. 

The    gall-bladder,   which    has  already    been   mentioned,   deserves 
further  notice.     Being  formed  as  an  outgrowth   from  the  duodenum 


20 


ANATOMY 


along  with  the  liver,  it  grows  forward  beneath  this  organ,  and  is  en- 
veloped in  peritoneum  except  along  its  hepatic  surface  (Fig.  14). 
Sometimes  a  fold  of  peritoneum  passes  nearly  directly  do\\Tiward  from 
the  fundus  of  the  gall-bladder  to  the  hepatic  flexure  of  the  colon 
(cystico-coHc  ligament),  but  more  frequently  the  peritoneum  covers 
the  under  surface  of  the  gall-bladder  closely,  and  passes  thence  to  the 
duodenum.  These  peritoneal  folds  have  been  particularly  studied 
by  Sencert   (1903). 


Pig.   14.- 


-Diagram  of  Peritoneal  Reflections  in  Transverse  Horizontal  Section  Through 
the  Head  of  the  Pancreas. 


1.  Cartilage  between  second  and  third    lumbar 
vertebrae. 

2.  Inferior  vena  cava. 

3.  Liver. 

4.  Ascending  colon. 

5.  Head  of  pancreas. 

6.  Gall-bladder. 


7.  Descending  duodenum. 

8.  Small  intestines. 

9.  Peritoneal  cavity. 

10.  Descending  colon. 

11.  Left  kidney. 

12.  Aorta. 


The  cystic  duct  is  from  2.5  to  6.5  cm.  in  length,  and  joins  the  hepatic 
duct  at  an  acute  angle,  to  form  the  common  bile  duct.  The  cystic 
duct  is  about  2.5  mm.  in  diameter.  The  hepatic  duct  is  usually  only 
2.5  to  4  cm.  in  length,  and  is  formed  by  the  coalescence  of  the  right  and 
left  bile  ducts  descending  from  the  liver.  Its  diameter  is  4  to  6  mm. 
The  common  bile  duct  is  from  2.5  to  7  cm.  or  more  in  length,  compen- 
sating for  the  shortness  of  the  other  ducts  when  they  are  of  less  than 
average  length.  It  is  about  6  mm.  in  diameter.  It  ordinarily  com- 
mences a  little  above  the  upper  level  of  the  pylorus,  and  passes  down 


PERITONEAL    REFLECTS 


21 


Fig.    15. — Diagram  of  Peritoneal  Reflections  after  Removal  of  all  Viscera. 


Suspensory  of  falciform  ligament  of  liver. 
Extraperitoneal    area    between    layers  of 
right  coronary  ligament  of  liver,  with  vena 
cava. 

Right  lateral  ligament  of  liver. 
First    part    of    duodenum    with    hepatic 
artery.      Between    duodenum    and    right 
coronary  ligament  of  liver,  is  the  foramen 
of  Winslow. 

Retroperitoneal  course  of  duodenum  sur- 
rounding head  of  pancreas. 
Mesentery  of  jejuno-ileum. 
Ascending  meso-colon. 


13. 


Left  lateral  ligament  of  liver. 
Cardiac    orifice    of   stomach,    with 
gastric  or  coronary  artery  just  below 
it. 

Splenic  artery  in  the  gastro-splenic 
omentum. 

Superior    mesenteric    artery,     sec- 
tioned;   the  duodenum  passes    be- 
tween it  and  the  aorta. 
Descending  meso-colon. 
Meso-sigmoid 


22 


ANATOMY 


behind  this  and  in  front  of  the  pancreas,  until  it  is  joined  on  its  poste- 
rior side  by  the  pancreatic  duct  (Fig.  16).  As  it  passes  downward 
it  may  be  completely  enclosed  in  pancreatic  tissue.  This  is  the  case 
in  about  two-thirds  of  the  cases  examined  at  autopsy.  The  combined 
pancreatic  and  bile  ducts  then  traverse  the  postero-internal  duodenal 
wall  obliquely  for  about  2  cm.  and  empty  into  the  interior  of  the  de- 
scending duodenum  about  7  to  10  cm.  beyond  the  pylorus.  To  obtain 
a  good  v-iew  of  this  opening  it  is  necessary  to  open  the  anterior  duodenal 
wall,  when  the  orifice  of  these  ducts  will  be  perceived  as  a  slight  pro- 


FlG.  16. — The  Bile  Ducts  and  Their  Relation  to  the  Duodenum  and  Pancreas. 

jection  of  the  mucous  membrane  (papilla  of  Vater)  guarded  on  its 
superior  surface  by  a  further  fold  or  hood  of  mucous  membrane,,  which 
is  provided  with  a  frenum  (Fig.  17).  Other  similar  folds  are  sometimes 
found  surrounding  the  papilla  of  Vater  on  all  sides.  Gall  stones  not 
infrequently  lodge  in  the  dilated  portion  of  the  duct  known  as  the  am- 
pulla of  Vater,  just  outside  the  duodenal  opening. 

The  arterial  supply  of  the  liver  is  conveyed  to  it  almost  entirely 
through  the  hepatic  artery,  a  branch  of  the  celiac  axis.  By  a  some- 
what semicircular  course,  with  the  convexity  forward,  this  artery 
passes  across  the  inferior  border  of  the  foramen  of  Winslow  to  reach 
the  upper  border  of  the  pylorus,  where  it  enters  the  gastro-hepatic 


LWER 


23 


omentum,  holding  here  a  position  to  the  left  and  in  front  of  the  portal 
vein,  which  lies  behind  and  between  the  hepatic  artery  and  the  bile 
duct.  Its  length  is  from  4  to  5  cm.  and  in  diameter  it  is  not  far  from 
6  mm.  On  reaching  the  transverse  fissure  of  the  liver  or  before,  the 
hepatic  artery  divides  into  two  or  more  branches:  of  these,  one  passes 
obliquely  to  the  right,  usually  behind,  but  occasionally  in  front  of,  the 
bile  ducts,  and  gives  off  the  cystic  artery  to  the  gall-bladder  (Fig.  16). 
The  cystic  artery  lies  between  the  cystic  and  hepatic  ducts  crossing 
sometimes  in  front,  sometimes  behind  the  hepatic  or  common  duct,  and 


Fig. 


-Interior  of  Stomach,  Pylorus,  and  Duodenum,  Showing  Papilla  of  Vater,  also 
Orifice  of  Duct  of  Santorini. 


on  reaching  the  neck  of  the  gall-bladder  divides'into  a  superior  and  an  in- 
ferior branch  which  supply  the  corresponding  surfaces  of  the  gall-bladder. 
The  left  hepatic  artery,  which  is  shorter  than  the  right,  passes  to  the  left 
extremity  of  the  transverse  fissure,  and  supplies  branches  to  the  Spigelian 
and  left  lobes  of  the  liver.  The  number  and  course  of  these  terminal 
branches  of  the  hepatic  artery  is  exceedingly  variable. 

The  veins  of  the  liver  collect  the  blood  within  its  lobules,  and,  by 
radicles  of  gradually  increasing  size,  finally  empty  by  two  or  three 
trunks  directly  from  its  posterior  surface  into  the  inferior  vena  cava. 
Except  for  semilunar  folds  at  the  entrance  of  these  veins  into  the  vena 


24  ANATOMY 

cava,  no  valves  exist  throughout  the  hepatic  veins.  The  blood  is 
urged  onward  largely  by  the  alternate  contraction  and  expansion  of 
the  liver  which  occurs  during  respiration. 

The  portal  vein,  as  is  well  known,  is  formed  in  front  of  the  body  of 
the  hrst  lumbar  vertebra  by  the  junction  of  the  superior  mesenteric 
and  splenic  veins.  At  its  origin  it  lies  between  the  head  of  the  pan- 
creas in  front  and  the  inferior  vena  cava  behind.  Then  passing  behind 
the  pylorus  and  first  part  of  the  duodenum,  it  enters  the  folds  of  the 
gastro-hepatic  omentum.  King  behind  and  between  the  hepatic  artery 
on  the  left  and  the  bile  duct  on  the  right.  In  the  connective  tissue 
which  sunounds  it  lie  numerous  filaments  of  the  hepatic  plexus  of  the 
sympathetic  nerve,  as  well  as  some  eft'erent  lymphatics  from  the  liver. 
On  reaching  the  transverse  fissure,  the  portal  vein  divides  into  two 
branches,  right  and  left,  distributed  to  the  corresponding  lobes  of 
the  liver.  The  main  trunk  is  about  7  to  lo  cm.  in  length.  The  portal 
system  of  veins  drains  the  stomach,  the  whole  of  the  small  intestine, 
the  vermiform  appendix,  the  cecum,  the  ascending,  the  transverse,  and 
most  of  the  descending  colon,  as  well  as  the  spleen  and  the  pancreas. 
The  cj'stic  vein  of  the  gall-bladder  also  empties  into  the  portal  vein. 

There  are  certain  definite  connections  between  the  portal  vein  and 
the  systemic  veins,  which  are  of  importance  in  various  hepatic  con- 
ditions. These  connections  may  be  classified  as:  (i)  those  within  the 
falciform  ligament  of  the  liver,  namely,  a  small  vein  which  sometimes 
is  present,  as  the  remains  of  the  umbilical  vein,  and  other  small  \eins, 
known  as  para-umbilical  veins,  which  surround  the  roimd  ligament  of 
the  liver  and  anastomose  with  the  epigastric  and  mammary  veins  of 
the  abdominal  wall;  (2)  anastomoses  between  various  radicles  of  the 
portal  system  and  veins  of  the  posterior  abdominal  wall — as  between 
those  of  the  pancreas,  of  the  duodenum,  and  of  the  ascending  colon, 
with  veins  of  the  posterior  abdominal  wall,  such  as  the  lumbar  veins, 
the  azygos  veins,  etc.;  (3)  between  the  superior  hemorrhoidal  veins 
(tributaries  of  the  portal)  and  the  middle  and  inferior  hemorrhoidal 
veins  (tributaries  of  the  internal  iliac  veins);  (4)  certain  anastomoses  . 
between  the  tributaries  of  the  coronary  veins  and  the  esophageal 
veins;  and  (5)  between  the  veins  of  the  portal  system  and  the  phrenics, 
at  the  uncovered  area  of  the  liver.  Of  these  various  communications 
the  most  important  are  the  first,  third  and  fourth  classes,  especially  the 
third  and  fourth.  Portal  obstruction  may  produce  the  "caput  Med- 
usas" around  the  umbilicus  in  afi'ecting  the  veins  of  the  falciform  liga- 
ment; in  this  case  the  current  of  blood  flows  away  from  the  umbilicus 
and  the  para-umbilical  veins.     But  if  the  "caput  Medusae"  is  due  to 


LIVER  2  5 

obstruction  of  the  inferior  vena  cava,  then  the  course  of  the  blood  is 
reversed,  and  it  drains  toward  the  navel  into  the  veins  of  the  round 
hgament!  In  such  cases  there  is  also  sometimes  enlargement  of  a 
superficial  vein  connecting  the  epigastric  or  external  ihac  vein  with 
the  axillary,  which  is  easily  detected  as  it  runs  up  the  side  of  the  ab- 
domen and  chest.  Enlargement  of  veins  in  the  second  classification 
is  seen  chiefly  where  the  pancreas,  duodenum,  etc.,  are  bound  down  by 
adhesions,  and  their  normal  drainage  into  the  portal  system  is  inter- 
fered with.  Hemorrhoids,  one  of  the  most  annoying  and  constant 
symptoms  of  portal  obstruction,  are  produced  by  overdistention  of  the 
superior  rectal  veins;  and  as  the  communication  between  them  and  the 
middle  and  inferior  hemorrhoidal  veins  is  free,  all  three  sets  of  rectal 
veins  are  frequently  found  to  be  varicose.  The  importance  of  varicose 
veins  of  the  esophagus  as  a  symptom  of  portal  obstruction  is  now  well 
recognized,  and  we  have  knowledge  of  more  than  one  patient  who  has 
bled  to  death  from  the  rupture  of  unsuspected  varicose  esophageal  veins. 
The  lymphatics  of  the  liver  are  divided  into  internal  and  external. 
The  former  accompany  the  branches  of  the  hepatic  and  portal  veins, 
and  are  not  of  so  great  surgical  importance  as  the  external  set.  Those 
accompanying  the  hepatic  veins  empty  into  the  lymph  nodes  situated 
on  the  upper  surface  of  the  diaphragm  just  above  the  cava]  opening; 
while  the  lymph  vessels  accompanying  the  portal  veins  empty  into  the 
nodes  about  the  neck  of  the  gall-bladder  and  the  cystic  duct.  The 
external  lymphatics  of  the  liver  lie  under  its  peritoneal  covering,  and 
in  the  connective  tissue  of  the  capsule  of  Glisson,  and  all  drain  away 
from  the  interior  of  the  liver.  They  consist  of  several  groups:  (i) 
Those  on  the  upper  or  convex  surface:  (a)  Three  or  four  branches  pass 
forward  along  the  upper  surface  of  the  liver  into  the  falciform  ligament, 
where  they  unite  into  a  single  trunk  which  enters  the  chest  through  the 
small  diaphragmatic  opening  at  the  side  of  the  xiphoid  cartilage,  and 
joins  the  anterior  mediastinal  nodes,  eventually  emptying  into  the 
right  lymphatic  duct,  (b)  A  similar  group  turns  downward  over  the 
anterior  border  of  the  liver  to  its  under  surface,  passes  along  the  longi- 
tudinal fissure  to  the  transverse  fissure,  and  thence  to  the  nodes  of  the 
gastro-hepatic  omentum,  (c)  Some  lymphatics  from  the  superior 
surface  of  the  right  and  left  lobes  of  the  liver  pass  to  the  right  and  left 
lateral  ligaments,  and  enter  the  anterior  mediastinal  nodes  or  the  lower 
end  of  the  thoracic  duct.  (2)  The  external  lymphatics  from  the  under 
surface  of  the  liver  may  be  classified  as  follows:  (a)  Those  on  the  right 
of  the  gall-bladder  empty  into  the  lumbar  nodes;  (b)  those  on  the  left 
of  the  gall-bladder  pass  to  the  esophageal  nodes  and  to  the  nodes  along 


26  ANATOMY 

the  lesser  curvature  of  the  stomach;  and  (c)  those  surrounding  the 
gall-bladder  form  a  plexus  and  pass  to  the  nodes  of  the  gastro-hepatic 
omentum.  It  is  thus  seen  that  the  lymph  nodes  around  the  neck 
of  the  gall-bladder  and  in  the  gastro-hepatic  omentum  drain  the  follow- 
ing areas  of  the  li\er:  anterior  median  portion  of  the  convex  surface, 
gall-bladder  area,  and  all  of  the  inferior  surface  of  the  left  lobe;  as  well 
as  receive  the  deep  l\Tnphatics  which  run  with  the  branches  of  the  portal 
vein.  These  nodes,  therefore,  in  the  gastro-hepatic  omentum  are  the 
most  important  surgically  of  all  the  lymph  nodes  in  connection  with  the 
liver,  and  are  frequently  found  enlarged  in  gall-bladder  diseases,  in 
malignant  growths,  and  in  inflammations  of  the  liver,  as  well  as  in 
hepatic  cirrhosis.  They  are  also  sometimes  enlarged  in  Hodgkin's 
disease,  and  by  compression  of  the  portal  vein  have  been  said  to  cause 
ascites  in  this  affection;  but  this  latter  action  has  been  questioned. 
As  Rolleston  (1905)  has  pointed  out,  neoplasms  may  work  their  way 
into  the  liver  by  the  portal  fissure  against  the  lymph  stream  which 
normally  flows  outward  in  this  location.  It  is  well  recognized  that 
h-mph  currents  are  very  easily  reversed  by  obstruction  to  their  normal 
course. 

The  nerve  supply  of  the  liver  has  recently  been  studied  by  Latarjet, 
Bonnet  and  Bonniot  (1920):  they  recognize  a  main  gastro-hepatic 
nerve,  which  runs  in  the  gastro-hepatic  omentum  from  the  left  (an- 
terior) pneumogastric  nerve  and  plexus  to  the  liver.  The  main 
sympathetic  nerves  arise  in  the  celiac  plexus:  from  the  semilunar 
ganglion  the  posterior  hepatic  plexus  travels  across  the  hepatic  artery 
and  along  the  left  side  of  the  choledochus  and  hepaticus  to  the  liver; 
while  the  anterior  hepatic  plexus  travels  along  the  right  side  of  the 
choledochus  to  the  liver.  The  right  phrenic  nerve  is  also  connected 
with  the  hepatic  nerve;  it  is  derived  mainly  from  the  fourth  cer- 
vical nerve,  which  also  sends  a  branch — the  supra-acromial  nerve — 
to  the  integument  of  the  point  of  the  shoulder,  thus  explaining  the 
"shoulder-tip  pains"  encountered  in  certain  hepatic  affections. 

The  disposition  of  the  peritoneum  and  the  relations  of  neighboring 
organs  to  the  liver  form  what  was  well  described  by  M.  H.  Richardson 
as  the  ''liver  pouch."  This  is  of  vast  importance  in  preventing  infec- 
tion of  the  general  peritoneal  cavity  in  diseases  of  the  gall-bladder  and 
other  organs  in  the  upper  right  abdominal  quadrant.  Limited  by  the 
under  surface  of  the  right  lobe  of  the  liver  above,by  the  duodenum 
and  spinal  column  toward  the  median  line,  and  by  tKe  transverse 
mesocolon  below,  this  pouch  readily  collects  all  extravasated  fluids 
and  becomes  a  valuable  site  for  drainage,  which  may  in  some  instances 


DUODENUM  27 

be  most  readily  procured  by  an  incision  into  its  floor  from  the  loin, 
below  the  tip  of  the  twelfth  rib. 

Duodenum. — The  duodenum,  with  the  exception  of  its  first  portion, 
is  entirely  retroperitoneal,  and  is  covered  in  front  by  so  many  impor- 
tant structures  that  only  its  first  and  second  portions  are  readily  acces- 
sible during  life.  The  first  portion,  continuous  with  the  pylorus,  is 
easily  reached  above  the  transverse  colon,  and  to  the  left  of  the  gall- 
ducts.  The  descending  portion  is  best  exposed  by  dividing  the  outer 
layer  of  the  ascending  mesocolon  throughout  its  upper  third,  when  by 
rolling  the  hepatic  flexure  of  the  colon  together  with  the  pylorus  toward 
the  patient's  left,  the  outer  and  posterior  walls  of  this  portion  of  the  duo- 
denum will  come  into  view ;  the  bile  and  pancreatic  ducts  are  thus  accessi- 
ble to  surgical  treatment  (Fig.  163).  To  expose  the  transverse  portion 
of  the  duodenum  the  least  dangerous  plan  is  to  divide  the  inferior  layer 
of  the  mesentery  of  the  small  intestine,  just  above  the  bifurcation  of 
the  aorta;  this  gives  access  to  the  duodenum  as  it  crosses  the  spinal 
column  immediately  below  the  superior  mesenteric  vessels.  In  Jabou- 
lay's  entero-anastomosis  (1902)  the  transverse  portion  of  the  duodenum 
on  the  right  of  the  superior  mesenteric  artery  was  utilized.  The 
duodeno-jejunal  flexure  is  readily  found  by  turning  the  transverse 
colon  upward  and  seeking  for  the  origin  of  the  jejunum  as  the  small 
intestine  emerges  from  beneath  the  transverse  mesocolon  (Fig.  18). 
Below  and  to  the  left  of  the  terminal  portion  of  the  duodenum,  with 
its  orifice  directed  upward,  is  the  duodeno-jejunal  fossa.  It  is  found  in 
about  48  per  cent,  of  cases,  and  may  be  the  seat  of  retroperitoneal 
hernia. 

The  relations  of  the  duodenum  to  surrounding  organs  have  already 
been  considered.  Of  these  the  most  important  are  its  relations  with 
the  gall-bladder  and  with  the  transverse  colon.  From  the  former  it  is 
separated  by  two  serous  surfaces,  the  visceral  layer  covering  its  first 
and  second  portions,  and  the  visceral  layer  of  the  gall-bladder  itself 
(Fig.  14).  Adhesions  are  frequent,  and  ulceration  of  the  duo- 
denum may  extend  into  the  gall-bladder,  or  vice  versa.  From  the 
transverse  colon  the  descending  duodenum  is  separated  only  by  a 
little  areolar  tissue,  there  being  no  peritoneum  between  the  two  organs 
wh(  re  the  root  of  the  transverse  mesocolon  crosses  the  duodenum. 
The  duodenum  is  fixed  in  its  position  not  only  by  its  retroperitoneal 
situation,  but  by  peritoneal  reflections  to  the  liver  and  gall-bladder  from 
its  initial  portion,  and  by  the  ligament  of  Treitz  from  the  duodeno- 
jejunal juncture  to  the  diaphragm.  Besides  these  means  of  fixation, 
there   are    the   insertion   of  the  bile  and  pancreatic  ducts,  and  the 


28 


ANATOMY 


proximity  of  the  superior  mesenteric  vessels  in  front  and  above  the 
duodenum. 

Ochsner  described  (1906)  a  sphincter  of  the  duodenum,  consisting 


Fig.  18. — The  Origin  of  the  Jejunum,  and  the  Duodeno-jejunal  Fossa,  Exposed  by  Turn- 
ing the  Transverse  Colon  Upward.     The  Jejuno-ileum  has  Been  Drawn  Far  to  the  Right. 


of  a  more  or  less  well  defined  band  of  thickened  circular  fibres,  usually 
some  distance  below  the  entrance  of  the  bile  and  pancreatic  ducts. 
He  thought  it  of  assistance  in  the  phase  of  duodenal  digestion  by  retain- 


PANCREASE 


29 


ing  the  chyme  in  the  duodenum  until  it  was  ready  to  be  discharged 
into  the  jejunum.  Boothby  (1907J  was  unable  to  confirm  the  exis- 
tence of  such  a  sphincter  in  any  of  25  specimens  examined  at 
autopsy. 

Pancreas. — The  pancreas,  which  is  also  retroperitoneal,  is  covered 
anteriorly  by  the  posterior  parietal  layer  of  peritoneum  which  forms 
the  lesser  peritoneal  cavity.  It  is  best  exposed  through  the  gastro- 
colic omentum  (Fig.  159),  or  by  passing  beneath  the  great  omentum 
and  detaching  this  from  the  transverse  colon  (Fig.  11).  Neither  of 
these  routes  gives  adequate  exposure  of  the  head  of  the  pancreas. 
The  posterior  portion  of  the  head  however,  may  be  partially  exposed 
by  mobilization  of  the  duodenum  (Fig.  163).  But  by  detaching  the 
great  omentum  from  the  transverse  colon,  and  then  dividing,  within 


Fig.  19. — The  Pancreas,  its  Ducts,  and  Their  Relation  to  the  Duodenum. 


the  lesser  peritoneal  cavity,  the  superior  layer  of  the  transverse 
mesocolon  over  the  pancreas,  a  fairly  free  exposure  of  this  organ 
throughout  its  whole  length  is  obtained. 

The  bloody  supply  of  the  pancreas  is  derived  chiefly  from  the  pan- 
creatic branches  of  the  splenic.  This  artery  runs  in  a  very  tortuous 
course  along  the  upper  border  of  the  pancreas.  The  pancreas  being 
situated  just  between  the  celiac  axis  above  and  the  superior  mesenteric 
vessels  below,  injuries  of  this  organ  are  frequently  fatal  from  hemor- 
rhage if  not  from  sepsis  or  interference  with  the  digestive  functions. 
The  close  relation  borne  by  the  pancreas  to  the  posterior  wall  of  the 
stomach  explains  the  frequency  with  which  this  organ  is  involved  in 
carcinoma  of  the  stomach.  Primary  carcinoma  may  also  affect  the 
pancreas,  and  the  growth,  if  it  involves  the  head  of  the  organ,  may  cause 


30  ANATOMY 

occlusion  of  the  common  bile  duct  and  consequent  jaundice.  If  the 
malignant  growth  affects  that  part  of  the  organ  in  relation  with  the 
aorta,  it  may  simulate  aortic  aneurism  by  causing  a  swelling  over  which 
transmitted  pulsation  is  detected. 

The  lymphatics  of  the  pancreas  are  discussed  in  Chapter  XXI  in 
connection  with  infection  of  this  organ. 

The  nerves  of  the  pancreas  are  branches  of  the  splenic  plexus  of  the 
sympathetic. 


CHAPTER  II 
PHYSIOLOGY  OF  DIGESTION 

The  region  of  the  upper  abdomen  includes  practically  all  of  that 
portion  of  the  intestinal  tract,  with  its  annexed  glands,  concerned  in 
the  process  of  digestion.  Although  the  intestines  below  the  duo- 
denum serve  as  a  receptacle  for  the  ingested  food,  and  although  the 
succus  entericus  has  certain  important  functions  to  perform  upon  the 
ingesta,  yet  these  parts  of  the  digestive  tube  are  concerned  more 
particularly  in  the  processes  of  absorption  and  elimination  than  in  that 
of  digestion. 

No  less  striking  than  the  development  of  the  surger>-  of  the  ab- 
domen in  recent  years,  are  the  valuable  contributions  to  our  knowl- 
edge of  the  physiology  of  digestion  which  are  products  of  the  same 
period.  There  is  no  better  illustration  of  the  fact  that  the  solution 
of  physiological  problems,  which  has  baffled  master  minds  of  bygone 
days,  has  been  rendered  possible  only  by  the  employment  of  modern 
surgical  methods  in  investigations,  than  the  fact  that  the  observations 
of  Beaumont  upon  Alexis  St.  Martin,  who  had  a  gastric  fistula  caused 
by  a  gunshot  wound,  have  been  considered  authoritative  from  1825 
until  recent  times.  The  results  of  modern  investigation  have  such 
important  clinical  relations  to  the  surgery  of  the  digestive  system 
that  they  well  merit  consideration  here. 

Intricate  though  the  processes  of  digestion  may  seem  at  first  sight, 
a  knowledge  of  embryology  renders  these  problems  simple.^ 

Perusal  of  the  preceding  chapter  has  revealed  the  fact  that,  in  the 
fetus,  the  alimentary  canal  early  assumes  the  form  of  a  straight  tube. 
A  portion  of  this  tube  becomes  dilated,  and  forms  the  stomach.  New 
relations  are  estabhshed  by  rotation  of  the  stomach  and  intestines. 
Evaginations  of  the  wall  of  the  duodenum  create  two  essential  glands, 
— the  liver  and  the  pancreas.  Ana'lysis  of  this  growth-process  im- 
presses one  at  the  outset  with  two  striking  features:  first,  the  very  early 
appearance  of  the  rudiments  of  the  liver  and  pancreas,  and  secondly, 
the  great  extent  of  intestinal  coiling.     The  tirst  feature  suggests  that 

'  As  W.  J.  Mayo  expresses  it,  man  prepares  his  food  with  the  organs  which  have  their 
origin  in  the  foregut,  and  absorbs  his  nutrition  from  the  derivatives  of  the  midgut;  that  is, 
he  eats  with  the  jejunum  and  the  ileum  and  drinks  with  the  cecum. 

31 


32  PHYSIOLOGY  OF  DIGESTION 

glandular  activity  is  to  be  closely  associated  with  the  workings  of  the 
digestive  tube.  As  a  matter  of  fact,  the  latter  is  lined  from  the  lips  to 
the  anus  with  countless  glands.  The  development  of  any  gland  is  very 
simple,  but  specialization  occasions  complexity.  Cylindrical  ingrowth 
of  the  epithelium  (which  in  this  case  lines  a  cavity)  into  underlying 
tissue,  with  subsequent  hoUowing-out  of  the  cylinders,  constitutes  a 
gland  of  the  simple  unbranched  tubular  type,  such  as  is  present  in  the 
fundus  of  the  stomach,  or,  asLieberkiihn's  glands,  throughout  the  small 
and  large  intestines.  Offshoots  from  the  cylinders  establish  the  tj-pe  of 
simple  branched  tubular  glands,  represented  by  the  countless  small 
serous  and  mucous  glands  of  the  oral  cavity,  and  by  the  glands  at  the 
pylorus  of  the  stomach  and  in  the  duodenum  (Brunner's  glands).  If 
the  endings  of  the  epithehal  plugs  expand  and  secondarily  give  rise  to 
primary  alveoli,  there  is  produced  the  racemose  type  of  glands,  such  as 
the  salivary  glands  and  pancreas.  Further  and  more  complicated 
modifications  of  structure  produce  a  reticular  tubular  gland,  such  as  the 
Hver,  in  which  instance  the  anastomosis  between  the  branches  of  the 
tubular  glands  is  so  extensive  that  a  net-like  structure  is  produced. 
The  salivarj'  glands,  pancreas,  and  liver  are  distinguished  by  ducts  of 
various  lengths,  so  that  we  may  designate  them  extra-mural  glands. 
To  sum  up,  therefore,  we  are  impressed  with  the  fact  that  innumerable 
glands  Une  the  digestive  tube,  and  that,  where  the  requirements  of  the 
organism  demand  it,  several  glands  are  further  developed  and  spe- 
cialized, and  are  removed  from  the  walls  of  the  digestive  tube  to  undergo 
further  enlargement,  but  are  still  connected  with  this  tube  by  ducts  of 
var>-ing  lengths.  The  aggregate  of  output  of  these  glands  is,  therefore, 
very  considerable.  Sappey  has  calculated  that  the  surface  of  the 
mucous  membrane  of  the  human  stomach  presents  over  5.000.000 
orifices  of  gastric  glands. 

Digestion  may  be  defined  as  a  mechanical  and  chemical  process 
by  which  food  is  prepared  for  absorption.  Of  course  it  is  useless,  in  a 
work  which  aims  to  treat  of  practical  questions  in  the  surgery  of  the 
upper  abdomen,  to  discuss  at  length  the  various  theories  and  facts  in- 
volved in  the  study  of  human  digestion;  but  it  is  unavoidable  to  ofifer 
readers  of  such  a  work  some  sort  of  reference  chapter,  which  will 
serve  to  illustrate  the  main  principles  of  physiology  involved,  and  will 
enable  them  to  apply  their  knowledge  when  discussing  the  path- 
ology and  treatment. 

Digestion  means  the  intake  of  food,  its  mastication,  its  exposure  to 
the  action  of  various  secretions,  to  intestinal  movements,  to  absorption 
and  finally,  if  of  no  further  use  to  the  organism,  its  ehmination.     Xa- 


FOOD    STUFFS  ^^ 

ture  prepares  a  very  difficult  gauntlet  for  the  food  to  run,  so  as  to  ex- 
tract from  it  every  possible  iota  of  nutrition.  Prolonged  contact  with 
the  food  is  secured,  in  the  first  instance,  by  coiling  of  the  small  bowel, 
and  sacculation  of  the  large;  and,  secondarily,  by  the  presence  of  the 
valvulae  conniventes  and  villi  in  the  small  intestine.  Not  only  is  the 
area  of  absorption  incalculably  increased  in  this  way,  but  also  the 
capacity  of  secretion  is  greatly  augmented. 

As  regards  function,  practically  all  of  the  glands  in  connection  with 
the  gastro-intestinal  tract  are  capable  of  secreting  mucus,  the  lubricant. 
Some  few  secrete  serous  fluid,  the  diluent.  To  fewer  still  is  reserved 
the  property  of  secreting  more  highly  specialized  products,  the  enzymes. 
Two,  the  liver  and  pancreas,  are  concerned  also  in  internal  secretion. 

Food  stuffs,  as  we  all  know,  are  classed  as  Proteids,  Carbohydrates, 
and  Fats,  respectively  represented  by  meats,  by  sugars  and  starches 
(rice,  macaroni,  bread,  etc.)  and  by  fatty  substances  such  as  butter, 
eggs,  cheese,  and  fat  of  meats.  When  digested  and  therefore  prepared 
for  absorption,  it  may  be  stated  with  sufficient  accuracy  that  proteids 
become  peptones,  that  carbohydrates  become  maltoses,  and  that  fats 
are  absorbed  practically  unchanged. 

The  proteid  is  acted  upon  by  three  agencies,  namely,  the  pepsin 
of  the  stomach,  the  trypsin  of  the  pancreas,  and  the  bacteria  in  the 
large  intestine.  The  carbohydrate  constituent  is  disposed  of  by  three 
agencies,  the  ptyalin  of  the  parotid  glands,  the  amylopsin  of  the  pan- 
creas, and  amylolytic  enzymes  from  Lieberkiihn's  gland  of  the  small 
intestine.  The  fats  are  attacked  by  the  lipase  (steapsin)  of  the  pan- 
creas, an  enzyme  the  activity  of  which  is  enhanced  by  the  bile.  There 
are  other  less  important  enzymes. 

The  mechanical  part  of  digestion  is,  or  should  be,  performed  largely 
by  the  cooking  and  by  the  mastication  of  the  food.  After  being  swal- 
lowed, the  action  of  the  stomach  consists  both  in  a  churning  movement 
which  mixes  the  bolus  of  food  with  the  gastric  juices,  as  well  as  in  a 
rhythmic  peristalsis  by  which  the  food  is  from  time  to  time  urged  for- 
ward into  the  duodenum.  Beyond  the  pylorus,  practically  the  only 
mechanical  action  to  which  the  ingesta  are  subjected,  apart  from  the 
peristaltic  motion  of  the  intestines,  is  represented  by  the  dilution  which 
they  undergo  by  admixture  with  the  bile  and  with  the  pancreatic  and 
intestinal  juices.  So  great  is  this  dilution  that  although  much  of  the 
fluid  portion  of  the  food  is  absorbed  while  passing  through  the  small 
intestine,  yet  even  when  the  cecum  is  reached  the  intestinal  contents 
are  always  very  soft,  and  usually  semifluid. 

From  the  standpoint  of  anthropology,  cooking  of  foods  is  not  essen- 

3 


34  PHYSIOLOGY  OF  DIGESTION 

tial  to  the  welfare  of  mankind,  but  is  a  product  of  civilization.  This 
trespass  upon  Nature  has  resulted  in  an  inherited  tendency  of  the 
human  teeth  toward  premature  decay  on  account  of  decreased  necessity 
for  the  grinding  action.  The  possession  of  poor  teeth  predisposes  to 
gastro-intestinal  aiJections,  whilst  a  good  set  acts  as  a  powerful  pro- 
phylactic. However,  cooking  of  meat  sets  free  the  muscle  fibres  by 
its  action  on  the  connective  tissue,  which  it  partly  transforms  into 
gelatin.  Cooking  of  vegetables  springs  the  pellicle  and  renders  the 
starch  more  soluble.  In  bread  baking,  the  dough  is  spongified  by  the 
carbonic  acid  formed  from  the  yeast.  Furthermore,  cooking  kills 
parasitic  ova,  and  renders  food  sterile. 

The  prephase  of  digestion  is  initiated  by  the  senses  of  sight,  smell, 
and  hearing,  and  also  by  the  thought  of,  and  longing  for,  food.  Care- 
ful and  attractive  preparation  of  food,  and  savory  odors  that  emanate 
from  it,  powerfully  whet  the  appetite.  Appetite  may  be  stimulated 
through  the  sense  of  hearing,  by  clatter  of  dishes  and  the  sizzling  of  meat 
directly  removed  from  the  fire.  The  craving  for  food  is  instinctive, 
and  is  the  basis  of  the  appetite. 

Salivary  Digestion. — These  psychic  events  bring  about  a  flow  of 
saliva,  as  a  preparatory  step  to  the  introduction  of  food  into  the  mouth. 
The  presence  of  food  in  the  mouth  causes  additional  flow  of  saliva, 
which  now  is  adapted  to  the  character  of  the  material  ingested.  The 
secretion  from  the  parotid  glands  is  serous,  and  contains  the  enzyme, 
pt3-alin;  that  from  the  sublingual  and  numerous  minute  glands  in  the 
mouth  is  mucous,  whilst  the  secretion  of  the  submaxillary  glands  is 
mixed,  serous  and  mucous.  By  moistening  the  food,  saliva  aids  masti- 
cation, and  by  enveloping  the  hard  and  bulky  bolus  with  mucin,  it 
facihtates  deglutition.  It  dissolves  the  soluble,  a  step  necessary  for 
inauguration  of  taste  sensations.  Furthermore,  saUva  is  protective 
in  that  it  tests  materials  introduced  into  the  mouth,  neutralizing  dele- 
terious properties,  rejecting  the  harmful,  and  washing  out  injurious 
substances  which  might  enter  the  blood  through  contact  with  the 
mucous  membrane.  A  specific  excitability  is  manifested  by  the  sali- 
vary glands,  since  fresh,  moist  food  creates  but  little  secretion,  whilst 
dry  materials  induce  a  copious  flow.  The  amylase  (ptyahn)  from  the 
parotid  gland  changes  starch  into  dextrin  and  maltose.  Owing  to  the 
short  stay  of  food  in  the  mouth,  salivary  digestion  takes  place  chiefly 
in  the  stomach.  Although  destroyed  by  gastric  juice,  yet  ptyalin 
continues  its  action  in  the  interior  of  the  bolus  of  food  until  the  gastric 
juice  has  completely  penetrated  the  mass,  a  process  which  requires  from 
20  to  40  minutes. 


GASTRIC    DIGESTION  35 

Gastric  Digestion. — Before  the  food  reaches  the  stomach,  gastric 
juice  has  been  secreted  by  the  innumerable  tubular  glands  which  stud 
thickly  the  gastric  mucosa.  The  excitant  of  this  preliminary  flow  is 
psychic;  in  fact  it  resides  in  the  appetite,  and  hence  we  may  speak  of 
"appetite-juice."  The  latter,  which  appears  within  5  minutes,  is 
copious  in  amount,  and  strong  in  digestive  power.  A  good  appetite  in 
eating  is  equivalent  from  the  outset  to  a  vigorous  secretion  of  the  strong- 
est juice;  lacking  appetite,  this  juice  is  also  absent.  Restoration  of 
appetite  means  gastric  juice  in  plenty,  wherewith  to  inaugurate 
digestion. 

The  qualitative  secretion  of  the  gastric  glands  varies  in  diiiferent 
parts  of  the  stomach.  In  the  fundic  region  pepsin,  rennin,  and  scanty 
amounts  of  hydrochloric  acid  are  secreted;  in  the  pre-pyloric  region  the 
same  substances  and  most  of  the  hj^drochloric  acid,  the  latter  fact  being 
indicated  by  the  deeper  red  color  of  the  mucous  membrane  in  this  area; 
whilst   in  the  pyloric  region  pepsin  and  rennin  only  are  produced. 

In  the  stomach  the  ingesta  undergo  equalization  of  temperature, 
maceration  by  the  gastric  juice,  and  conversion  into  chyme.  Although 
ptyalin  is  destroyed  in  an  acid  medium,  yet  salivary  digestion  of 
carbohydrates  may  proceed  for  30  minutes  in  the  stomach,  not  only 
on  account  of  the  slight  acidity  of  the  gastric  juice  in  the  fundus  where 
the  food  first  lodges,  but  also  because  of  the  length  of  time  required 
for  complete  penetration  of  each  bolus  of  food  by  the  gastric  juice. 
The  copious  amount  of  "appetite-juice"  is  now  augmented  by  a 
second  quantity  of  juice,  produced  chemically.  The  first  comp- 
lement of  juice  decreases  in  amount  as  the  second  increases.  The 
latter  depends  on  the  production  in  the  pyloric  mucous  membrane  of  a 
specific  substance  or  hormone,  which  acts  as  a  chemical  messenger  to 
all  parts  of  the  stomach,  being  absorbed  into  the  blood  and  thence 
e.xciting  the  activity  of  the  various  secreting  cells  in  the  gastric  glands. 

Just  as  the  acidity  of  the  gastric  juice  is  detrimental  to  the  action 
of  ptyalin,  so  is  it  essential  for  the  action  of  the  ferment,  pepsin. 
During  the  time  usually  occupied  by  gastric  digestion,  namely,  from 
3  to  6  hours,  proteids  are  prepared  by  the  pepsin-hydrochloric  acid 
for  subsequent  digestion  by  the  enzyme,  trypsin,  in  the  small  intestine. 
With  this  end  in  view,  most  of  the  proteid  is  converted  in  the  stomach 
into  its  first  products  of  hydration,  namely,  peptones  and  proteoses, 
in  which  state  the  proteids  of  the  food  are  normally  passed  on  into 
the  duodenum,  having  been  rendered  more  amenable  to  the  action  of 
trypsin.  Therefore,  disposal  of  proteids  occurs  in  the  cycle  of  peptic- 
trj^tic  digestion. 


36  PHYSIOLOGY  OF  DIGESTION 

Rennin  possesses  the  specific  action  of  curdling  milk,  which  is 
brought  about  by  the  coagulation  of  caseinogen. 

Fat  undergoes  no  digestive  change  in  the  stomach.  It  is  merely 
liquefied  by  the  bodily  heat,  dissociated  from  other  foods  by  the 
specific  proteolytic  action  of  the  pepsin-hydrochloric  acid,  and  mixed 
with  the  chyme  in  the  form  of  a  coarse  emulsion.  Fat  inhibits  the 
work  of  the  gastric  glands,  both  from  a  quantitative  and  from  a  quali- 
tative point  of  view:  hence  the  omission  of  fat  other  than  in  emulsion, 
from  a  corrective  dietary.  On  the  contrary,  water  and  extracts  of 
meat  exert  a  stimulating  effect  upon  the  secretion  of  gastric  juice. 

Absorption  from  the  stomach  is  very  slight,  although  alcohol  is 
absorbed  readily,  and  certain  soluble  drugs  may  be. 

Gastric  digestion  continues  until  the  whole  of  the  stomach  contents 
is  discharged  from  the  pylorus  as  the  semifluid  chyme.  After  this 
event,  the  stomach  enters  upon  a  resting  stage,  during  which  its 
cavity  is  nearly  obliterated. 

Intestinal  Digestion. — The  fluid  chyme,  on  entering  the  duo- 
denum, is  subject  at  once  to  the  influence  of  the  secretions  of  three 
different  sets  of  glands,  namely:  (i)  The  intestinal  glands,  including 
those  characteristic  of  the  duodenum,  called  Brunner's  glands;  (2) 
the  pancreas;  (3)  the  liver.  The  ducts  of  the  two  latter  in  man  have 
a  common  opening  into  the  duodenum,  and  there  is  a  co-operation 
between  all  three  juices  for  the  production  of  the  intestinal  digestive 
fluid. 

The  flow  of  pancreatic  juice  is  initiated  chemically.  The  epithe- 
lial cells  lining  the  intestines  contain  a  body — pro-secretin — which, 
under  the  influence  of  agents  such  as  acids,  undergoes  hydrolysis  with 
the  splitting  off  of  a  new  body,  termed  secretin.  The  latter,  on 
absorption  into  the  blood,  a.cts  as  the  chemical  messenger  (hormone) 
to  the  pancreatic  cells.     Sleep  does  not  hinder  pancreatic  secretion. 

The  pancreatic  juice  is  alkaline,  a  reaction  that  corresponds  closely 
in  degree  to  the  acidity  of  the  gastric  juice.  Aided  by  the  bile  and 
alkaline  juice  from  the  intestinal  glands,  the  pancreatic  juice  neutral- 
izes the  acid  chyme,  with  the  result  that  a  neutral  fluid,  in  which  the 
processes  of  intestinal  digestion  will  continue  is  produced  in  the  duo- 
denum. 

Secretion  of  pancreatic  juice  starts  shortly  after  entrance  of  food 
into  the  stomach,  and  rapidly  reaches  a  maximum  in  from  2  to  4 
hours,  whilst  by  the  seventh  hour  it  has  practically  ceased.  The 
character  of  the  food  modifies  the  composition  of  the  secretion.  The 
pancreatic  juice  when  it  reaches  the  duodenum  contains  three  enzymes, 


SECRETION    OF    BILE  37 

of  which  trypsin  is  proteolytic;  amylopsin,  amylolytic;  and  steapsin, 
lipol\'tic.  Secretion  evoked  by  proteids  abounds  in  trypsin;  that 
by  carbohydrates,  in  amylopsin;  and  that  by  fats,  in  steapsin. 

If  trypsin  be  proteolytic,  the  question  would  naturally  arise,  why 
should  not  this  enzyme  digest  the  intestinal  mucosa?  The  answer  is 
that  trypsin  is  not  a  secretion,  but  a  resultant.  The  secretion  is 
trypsinogen,  a  pro-enzyme,  which  is  converted  into  trypsin  by  entero- 
kinase,  a  product  of  the  duodenum  and  jejunum.  Therefore,  until 
enterokinase  trans-substantiates  trypsinogen  into  trypsin  by  catalysis, 
no  proteolysis  is  manifested. 

Trypsin  continues  the  transformation  of  proteids  which  was  begun 
in  the  stomach.  It  also  completes  the  cycle  of  peptic-tryptic  digestion. 
Trypsin,  however,  acts  more  rapidly  and  powerfully  than  pepsin, 
and  breaks  up  the  proteid  molecule  more  completely.  Thus,  the 
peptones  and  proteoses,  prepared  from  proteids  by  the  pepsin,  and 
delivered  by  the  stomach  into  the  duodenum,  are  further  split  by 
trypsin  into  amido-acids. 

Amylopsin  acts  upon  starches  in  very  much  the  same  way  as  does 
ptyalin.  The  carbohydrates  that  have  escaped  the  action  of  ptyalin 
are  hydrolyzed  in  the  duodenum,  by  amylopsin,  into  maltose  and 
dextrin;  and  these,  in  turn,  are  converted  into  dextrose  by  the  maltase 
of  the  succus  entericus. 

Steapsin,  materially  aided  by  bile,  splits  up  neutral  fats  into 
glycerin  and  free  fatty  acids. 

The  Secretion  of  Bile. — Since  bile  reaches  the  duodenum  through 
an  orifice  common  to  it  and  to  the  pancreatic  juice,  the  natural  infer- 
ence is  that  these  two  fluids  co-operate  in  their  action,  and  that  bile 
is  of  direct  use  in  digestion.  As  a  matter  of  fact,  bile  increases  the 
action  of  steapsin  two  to  three  fold,  and  that  of  trypsin  and  amylopsin 
about  two  fold.  Indeed,  bile  is  of  great  value  in  digestion,  and  plays 
an  important  role  in  this  process.  Beginning  almost  immediately 
after  taking  food,  the  secretion  of  bile  attains  its  maximum  with  the 
pancreatic  juice  in  the  third  hour,  is  regulated  by  the  same  laws  that 
govern  the  flow  of  other  digestive  juices,  and  then  rapidly  declines. 
Thus,  bile  is  produced  by  the  same  agent  as  pancreatic  juice,  namely, 
by  secretin.  Furthermore,  bile  flows  as  long  as  digestion  lasts,  but 
with  definite  fluctuations  in  quantity  and  quality,  dependent  upon 
the  nature  of  the  food. 

The  bile  is  being  constantly  formed  in  the  liver,  and,  during  the 
intervals  of  digestion,  is  stored  up  in  the  gall-bladder.  Its  pressure  is 
not  known  accurately,  but  is  delieved  to  be  always  greater  than  that  of 


38  PHYSIOLOGY  OF  DIGESTION 

the  blood  in  the  portal  vein.  In  amount  the  bile  varies  from  twenty  to 
twenty-seven  ounces  (600  to  8oo  cc.)  daily.  Its  descent  from  the  liver 
is  probably  aided  by  the  changes  in  the  bulk  of  the  liver  produced 
by  respiration,  as  well  as  by  the  vis  a  tergo  of  the  more  freshly  formed 
bile.  The  contractions  of  the  gall-bladder  which  are  usually  believed  to 
occur,  are  said  to  be  produced  by  sensory  stimulation  of  the  mucous 
membrane  of  the  stomach  or  duodenum  through  reflex  nervous  action. 
The  presence  of  chyme  in  the  duodenum  causes,  by  means  of  secretin, 
a  contraction  of  the  gall-bladder  and  a  relaxation  of  the  sphincter 
muscle  of  Oddi  surrounding  the  duodenal  orifice  of  the  bile  duct,  with 
consequent  ejection  of  bile.  There  is  so  little  muscular  tissue  in  the 
gall-bladder,  however,  that  it  is  doubtful  whether  the  gall-bladder 
does  more  than  equalize  the  pressure  in  the  bile  ducts,  like  the  air  cham- 
ber of  an  hydraulic  ram.  It  is  an  interesting  fact  that  even  though 
almost  the  whole  amount  of  bile  excreted  be  diverted  through  a  biliary 
fistula,  so  that  scarcely  any  of  it  reaches  the  intestinal  tract,  yet  never- 
theless the  individual  so  affected  may  continue  to  enjoy  good  health, 
showing  conclusively  that  bile  is  much  more  of  an  excretion  than  a 
secretion. 

To  sum  up,  the  chief  duty  of  the  bile  is  to  facilitate  the  transition 
from  gastric  to  intestinal  digestion,  since  it  enters  the  duodenum  at  a 
spot  where  the  acid  peptic  digestion  gives  place  to  alkaline  pancreatic 
digestion;  it  arrests  the  action  of  pepsin,  which  is  harmful  to  the  en- 
zymes of  the  pancreatic  juice,  and  reenforces  the  enzymes  of  the  latter, 
particularly  by  serving  as  a  vehicle  for  the  suspension  and  solution  of 
the  interacting  fats,  fatty  acids,  and  stcapsin. 

Not  only  is  bile  important  in  digestion,  but  further,  as  an  excretion, 
it  is  the  channel  by  which  the  disintegration-products  of  hemoglobin 
are  cast  out  from  the  organism. 

Succus  Entericus  increases  the  activity  of  the  pancreatic  enzymes. 
Just  as  bile  aids  particularly  the  action  of  the  pancreatic  lipolytic 
enzyme,  so  does  succus  entericus  augment  the  proteolytic.  Hence 
both  of  these  secretions  are  adjuvants  of  the  pancreatic  juice.  Se- 
cretin is  also  the  producer  of  succus  entericus. 

Succus  entericus  is  a  secretory  product  of  some  of  the  glands  of 
Lieberkiihn.  Collectively,  these  glands,  as  well  as  those  of  the  stomach, 
may  be  considered  as  an  enzyme-producing  entity  which,  instead  of 
being  gathered  together  to  form  an  extramural  organ,  such  as  the 
liver  or  pancreas,  is  distributed  throughout  the  intestinal  wall,  thence 
to  discharge  secretion  directly  into  the  lumen  of  the  intestine. 

Succus  entericus,  distinctly  alkaline  in  reaction  owing  to  sodium 


ABSORPTION  IN  THE  INTESTINES  39 

carbonate,  contains  four  or  live  enzymes  that  complete  the  digestion  of 
food-stuffs  begun  in  the  stomach  and  duodenum,  thus  exercising  a 
most  important  influence  upon  intestinal  digestion.  Of  these  enzymes 
two,  enterokinase  and  erepsin,  are  concerned  in  proteolysis.  Entero- 
kinase,  as  has  been  seen,  activates  the  proteolytic  enzyme  of  the  pan- 
creatic juice,  by  converting  the  trypsinogen  into  trypsin.  Erepsin 
supplements  the  work  begun  by  trypsin,  in  that  it  causes  further 
hydrolysis  of  peptones  and  proteoses. 

Secretin,  which  initiates  the  secretion  of  bile,  pancreatic  juice,  and 
succus  entericus,  is  not  an  enzyme,  but  a  definite  chemical  substance 
produced  in  the  intestinal  wall  in  a  preliminary  form,  pro-secretin, 
which,  influenced  by  acids,  is  converted  to  secretin.  The  latter  is 
absorbed  and  carried  to  the  glands,  the  secretion  of  which  it  evokes. 

The  remaining  enzymes  of  succus  entericus  are  concerned  in  the 
digestion  of  carbohydrates.  They  are  maltase,  invertase,  and  lactase, 
the  last  being  present  in  young  individuals  and  in  those  fed  through- 
out life  exclusively  upon  a  milk  diet.  Maltase  acts  upon  the  products 
of  the  digestion  of  starches,  namely,  maltose  and  dextrin,  converting 
them  into  dextrose.  Invertase  transforms  cane-sugar  into  dextrose 
and  levulose,  whilst  lactase  changes  milk-sugar  into  dextrose  and 
galactose. 

Absorption  in  the  Intestines. — In  consequence  of  all  these  changes, 
the  three  classes  of  food-stuffs  are  reduced  to  a  soluble  condition,  and  in 
solution  are  taken  up  by  the  cells  lining  the  intestine.  The  products 
formed  in  digestion  largely  disappear  between  the  duodenum  and  the 
ileocecal  valve.  Carbohydrates  are  absorbed  chiefly  as  simple  sugars — 
monosaccharids.  As  dextrose,  then,  the  sugars  pass  directly  into  the 
blood  stream,  by  which  they  are  distributed  first  to  the  liver  and  then 
to  other  organs  of  the  body.  In  the  liver  the  excess  of  sugar  is  removed 
from  the  blood  and  stored  as  glycogen.  Alimentary  glycosuria  is  a 
phenomenon  arising  from  ingestion  of  larger  amounts  of  carbohydrates 
than  the  liver  can  store  up  as  glycogen,  the  excess  being  removed  from 
the  blood  by  the  kidneys,  and  excreted  in  the  urine.  Any  carbohy- 
drates which  escape  absorption  as  sugar  are  apt  to  undergo  acid 
fermentation  from  the  action  of  the  bacteria  constantly  present  in  the 
intestine. 

Proteids,  hydrolyzed  during  digestion  into  peptones  and  proteoses, 
or  amido-acids,  probably  are  absorbed  as  such,  passing  directly  into 
the  blood-vessels  of  the  intestinal  vilU,  and  thence  into  the  blood  stream. 

Fats  are  absorbed  by  the  epithelial  cells  in  the  forms  of  fatty  acids 
and  glycerin,  which,  in  turn,  are  immediately  re-synthesized  into  in- 


40  PHYSIOLOGY  OF  DIGESTION 

soluble  neutral  fats  in  the  cells  themselves.  In  the  state  of  the  line 
emulsion — chyle — most  of  the  fats  reach  the  blood  stream  through  the 
lacteals  and  thoracic  duct.  Absorption  of  spht  fats  is  considerably 
aided  by  the  bile.  Some  of  the  fat  reaches  the  liver  by  way  of  the  blood 
stream,  and  undergoes  accumulation  in  that  organ.  If  an  excess  of  fat 
were  ingested,  of  if  the  flow  of  bile  were  decreased  or  stopped,  a  large 
percentage  of  fat  would  escape  absorption  and  appear  in  the  feces. 

The  secretion  of  the  large  intestine  is  alkahne,  and  contains  much 
mucus,  but  is  itself  devoid  of  enzymes,  those  that  are  present  having 
been  contributed  and  passed  along  by  the  small  gut.  Since  absorp- 
tion and  digestion  arc  not  completed  in  the  small  intestine,  they  are 
continued  in  the  large.  Furthermore  the  latter  absorbs  large  quan- 
tities of  water. 

Bacterial  Action. — The  bacteria  normally  found  in  the  intestinal 
tract  are  of  considerable  practical  importance.  At  birth  the  digestive 
tract  is  sterile,  but  as  soon  as  unsterilized  food  is  ingested  there  are 
found  bacteiia  of  various  kinds,  pre-eminently  the  colon  bacillus.  As 
has  been  shown  by  numerous  observers,  the  emptier  the  intestinal  tract 
is  of  food,  the  fewer  will  be  the  bacteria  present.  In  the  stomach, 
bacteria  disappear  with  the  food,  and  when  the  stomach  has  been  en- 
tirely empty  for  some  time,  its  cavity  is  nearly  sterile,  owing  to  the 
antiseptic  properties  of  the  gastric  juice.  According  to  the  investi- 
gations of  MacXeal  and  Chace  (1913)  the  fasting  duodenum  is  almost 
free  from  living  micro-organisms.  Certain  bacteria,  especially  Bacil- 
lus subtihs  and  Proteus  \-ulgaris,  are  believed  to  have  a  proteolytic 
action,  and  thus  to  aid  the  peptic  digestion.  The  duodenum  in  its 
upper  part  is  singularly  free  from  bacteria,  probably  due  to  the  acid 
gastric  juice;  but  as  the  small  intestine  is  traversed,  and  the  alkalinity 
of  its  contents  increases,  the  bacterial  content  becomes  greater  and 
greater,  reaching  its  maximum  in  the  lower  ileum ;  the  bacteria  are  less 
numerous  again  in  the  colon. ^  The  annexed  diagram  from  Gilbert 
and  Domenici  describes  these  changes  much  more  accurateh'  than  can 
mere  words  (Fig.  20).  It  is  worthy  of  note  that,  just  as  purgation 
eliminates  most  of  the  bacteria  with  the  intestinal  contents  so  pro- 
longed constipation  and  especially  intestinal  obstruction  markedly 
increase  the  virulence  ol  the  intestinal  bacteria. 

In  the  small  intestine,  bacteria  show  activity  by  fermenting  car- 
bohydrates.    This  process  exerts  a   restraining  effect   upon  proteid 

'  The  fact  that  injuries  of  the  large  bowel  are  more  apt  to  be  followed  by  peritonitis 
than  are  those  of  the  small  bowel  probably  may  be  explained  by  the  greater  virulence  of 
the  bacteria  (^especially  the  colon  bacilli  i  which  are  here  encountered. 


COMPOSITION    OF    THE    FECES 


41 


putrefaction,  which,  on  the  contrary,  is  a  constant  and  normal  oc- 
currence in  the  large  intestine.  In  this  way  proteids  that  have  escaped 
digestion  and  absorption  are  split  up  into  various  end-products,  some 
of  which  are  given  off  in  the  feces,  whilst  others  are  absorbed  in  part 
and  excreted  subsequently  in  the  urine.  The  extent  to  which  these 
bodies  occur  in  the  urine  is  an  indication  of  the  extent  of  putrefaction 
in  the  large  intestine,  a  fact  which  possesses  certain  clinical  value. 
Cellulose,-  for  which  there  is  no  specific  enzyme,  is  hj'drolyzed  by  bac- 
teria and  thus  rendered  useful  in  nutrition.  Aside  from  this,  it  may  be 
said  that  bacterial  fermentation  is  not  essential  for  the  welfare  of  the 
economy. 


100.000 

y 

30,000 

/ 

/ 

60,000 
SO.OOO 
toooo 
30.000 
20,000 
10.000 
0 

/ 

/ 

y 

/ 

1 

;                 ■ 

Stomach 

J)tiodenum. 

Jrjunnm 

Jlcum. 

Lar^tlatf.sti.nc 

Fig.  20.- 


-Graphic  Representation  of  the  Bacterial  Content  of  the  Gastro-intestinal  Tract. 
(Gilbert  and  Domenici,) 


Composition  of  the  Feces. — The  character  of  the  food  has  an 
important  influence  upon  the  composition  of  the  feces.  Upon  a  diet 
composed  exclusively  of  meats  they  are  small  in  amount  and  dark  in 
color;  with  an  ordinary  mixed  diet  the  amount  is  increased;  and  it  is 
largest  with  an  exclusively  vegetable  diet,  especially  with  vegetables 
containing  a  large  amount  of  indigestible  substances.  Feces  are 
made  up  of  indigestible  and  undigested  materials;  products  of  intestinal 
secretions  and  of  bacterial  decomposition;  cholesterin,  excretin, 
mucus  and  epithelial  cells,  pigment,  inorganic  salts,  and  micro- 
organisms. In  addition,  gas,  arising  from  bacterial  fermentation 
of  proteids,  is  present  in  varying  amounts. 

The  main  function  of  the  alimentary  tract,  therefore,  is  the  pres- 
entation to  the  tissues  of  the  body  of  the  food-stuffs  in  a  form  in  which 
they  are  directly  assimilable. 

Liver. — Our  knowledge  of  the  physiology  of  the  liver,  until  recent 
years,  has  consisted  in  acquaintance  with  the  facts  that  it  produced 
bile,  and  that  it  served  as  a  storehouse  for  carbohydrates,  absorbed  as 


42 


PHYSIOLOGY  OF  DIGESTION 


maltose  and  dextrose  from  the  intestines  through  the  portal  system  of 
veins,  and  stored  up  in  the  form  of  glycogen.  This  glycogen,  by  the 
metabolic  action  of  the  liver  cells,  may  be  again  converted  into  maltose 
as  occasion  demands,  and  be  given  off  into  the  general  circulation  for 
nutriment  to  the  muscles  and  other  structures  of  the  body.     Attempts, 


Fig.  21.- 


-Diagram  to  Show  the  Relation  of  the  Lobes  of  the  Liver  to  Various  Abdominal 
Structures,  Indicated  by  Blood.  Currents  in  the  Portal  Vein. 


however,  have  been  made  by  Silvestri  (1905)  and  others  to  specialize 
the  functions  of  the  right  and  left  lobe  of  the  liver.  As  has  been  known 
for  some  years,  the  right  lobe  of  the  Uver  is  especially  affected  by  en- 
largement  in   diabetes   (supposedly   a   pancreatic   disease);  while  in 


LIVER  4,3 

Bantis  disease,  and  other  splenomegalies,  the  left  lobe  is  more  particu- 
larly affected.  Silvestri  records  some  experiments  of  his  own,  and 
refers  to  others  by  Glenard  and  by  Serege,  which  tend  to  confirm  the 
idea  that  the  left  lobe  of  the  liver  is  intimately  connected  with  the 
stomach  and  the  spleen,  while  the  right  has  more  definite  relations 
with  the  pancreas  and  small  intestines.  Injections  of  staining  fluids 
into  the  spleen  invariably  produce  a  discoloration  in  the  liver  limited 
to  the  left  lobe;  while  similar  injections  into  the  superior  mesenteric 
radicles,  made  very  cautiously,  so  as  not  to  disturb  the  venous  current, 
always  stained  the  right  lobe  of  the  liver  much  more  than  the  left.  It 
is  to  be  hoped  that  some  practical  application  may  be  made  of  the  in- 
formation thus  gained. 

The  blood  pressure  in  the  portal  vein  and  in  the  liver  is  very  low, 
so  that  hemorrhage  from  the  liver  is  readily  controlled  by  pressure  or 
by  approximation  of  the  lips  of  the  wound  in  the  liver  by  sutures. 

The  internal  secretions  of  the  liver  and  pancreas  are  so  far  too  httle 
understood  for  anything  very  definite  to  be  said  about  their  physio- 
logical activity.  Their  relations  with  the  kinetic  system,  so  graph- 
ically described  by  Crile,  have  not  yet  been  shown  to  be  of  much 
practical  interest. 

One  of  the  most  interesting  of  the  functions  connected  with  the 
complemental  metabohsm  of  the  liver,  is  its  so-called  detoxicating 
power  over  certain  substances.  In  addition  to  its  influence  over 
certain  alkaloidal  and  mineral  poisons  (such  as  nicotin,  hyoscyamin, 
strychnin,  quinin,  atropin,  morphin,  antipyrin,  peptone,  and  certain 
toxins)  it  is  probable  that  the  Uver  exercises  a  somewhat  similar  de- 
toxicating power  over  certain  forms  of  bacteria  themselves.  It  is 
possible  that  incompetence  of  the  spleen,  which  normally  abstracts 
from  the  circulation  pathogenic  bacteria,  may  thus  overwork  the  liver 
and  in  turn  cause  it  to  become  incompetent.  For  the  liver  then  will 
have  to  deal  not  only  with  bacteria  arriving  from  the  intestinal  tract, 
but  also  with  those  which  pass  through  the  spleen.  The  state  known  as 
cholemia,  formerly  thought  to  be  caused  by  suppression  of  bile,  and 
therefore  analogous  to  uremia,  has  been  observed  sufficiently  often 
without  obstruction  to  the  flow  of  the  bile  to  render  it  certain  that  it  is 
caused  by  an  auto-intoxication  from  changes  in  the  liver  substance,  not 
due  to  the  damming  up  of  the  bihary  excretion.  For  although  it  is 
quite  probable  that  this  latter  condition  will  in  most  instances  so  injure 
the  liver  cells  as  to  be  productive  of  cholemia,  yet  other  factors  such  as 
biliary  cirrhosis  may  be  equally  destructive  to  the  liver,  while  the 
excretion  of  bile  remains  unimpaired. 


44  PHYSIOLOGY  OF  DIGESTION 

The  Movements  of  the  Alimentary  Tract. — Chemical  digestion 
is  supplemented  by  movements  of  the  alimentary  tract  which  provide 
mechanical  activity  necessary  for  the  following  purposes: — the  prepara- 
tion of  the  food  for  digestion  by  reducing  it  to  a  condition  of  fine  sub- 
division by  means  of  the  movements  of  mastication;  the  intimate 
mixing  of  the  food  with  the  digestive  juices,  so  as  to  allow  of  these 
coming  in  contact  with  every  particle;  the  propulsion  of  the  food  from 
one  cavity  of  the  canal  to  the  next  as  soon  as  the  processes  of  digestion 
in  the  first  cavity  have  been  completed;  and  finally  the  rejection  and 
expulsion  from  the  body  of  the  indigestible  portions  of  the  food-stuffs, 
mixed  with  the  products  of  excretion  of  the  alimentary  canal  itself. 

Bearing  in  mind  the  uniform  character  of  the  primitive  digestive 
tube,  one  would  naturally  expect  to  find  similarity  in  structure  of  the 
walls  of  the  matured  gastro-intestinal  tube.  As  a  matter  of  fact, 
aside  from  variations  brought  about  from  modifications  of  structure 
and  speciaUzations  of  function,  this  is  the  case.  The  serosa,  originally 
almost  a  complete  tunic,  becomes  ver}'  incomplete  in  those  parts  of  the 
tube  where  little  motion  occurs,  as  in  the  duodenum,  ascending 
and  descending  colon.  The  mucosa,  primarily  of  uniform  thickness, 
becomes  well-developed  where  glandular  activity  is  greatest,  as  is 
illustrated  by  the  thickness  of  the  gastric,  duodenal,  and  jejunal  mu- 
cosce,  and  the  relative  thinness  of  that  in  the  remainder  of  the  tube. 
In  Hke  manner,  where  much  work  is  required,  the  muscular  tunic  is 
well  developed,  and,  in  certain  locations,  is  specially  thickened  to  form 
sphincters.  Otherwise  it  is  thin  or  incomplete.  In  this  respect,  it 
may  be  compared  to  the  musculature  of  the  cardio-vascular  system. 
In  both  of  these  systems  the  circular  coat  is  developed  to  a  greater 
extent  than  the  longitudinal.  Unusual  muscular  effort  is  required  of 
the  heart  and  of  the  stomach,  and  in  both  there  is  an  additional  layer 
of  obliquely  disposed  muscular  fibres.  Each  is  the  seat  of  rhythmical  con- 
tractions. In  the  aorta  and  large  arterial  trunks,  on  the  one  hand, 
and  in  the  duodenum  and  jejunum,  on  the  other,  the  muscular  tunics 
are  well-developed.  In  the  smaller  arteries  and  the  ileum  the  mus- 
cular tissue  gradually  diminishes  in  amount.  Muscular  activity  in 
the  veins  and  large  intestine  is  reduced  almost  to  a  minimum,  and  in 
both  the  musculature  is  either  poorly  or  imperfectly  developed.  To 
complete  the  simile,  it  may  be  mentioned  that  the  heart  and  stomach 
are  supplied  both  by  the  pncumogastric  and  by  the  sympathetic 
nerves,  whilst  the  blood-vessels  and  intestines  receive  their  innervation 
from  the  sympathetic  system.  Finally,  both  the  heart  and  the  stomach 
possess   intramural   ganghon-cells,    which   are   capable   of   producing 


MOVEMENTS  OF  THE  STOMACH  45 

spontaneous  contractions  of  these  organs,  even  when  they  are  Uberated 
from  all  extrinsic  nervous  stimuli. 

Deglutition. — Mastication  reduces  solid  food  to  a  fine  pulp,  which 
the  tongue  forms  into  a  bolus.  A  peristaltic  contraction,  which  con- 
sists of  contraction  behind  the  mass  with  inhibition  and  relaxation 
in  front  of  it,  carries  the  bolus  down  to  the  stomach,  which  it  enters 
through  the  cardiac  orifice.  The  arrival  of  each  bolus  in  the  stomach 
can  be  detected  by  auscultating  the  back  of  a  patient  over  the  region 
of  the  cardiac  orifice,  which  corresponds  to  the  level  of  the  eleventh 
dorsal  vertebra.  A  gurgling  sound  is  heard  each  time  the  food  passes 
into  the  stomach.  Normally  this  occurs  from  three  to  seven  seconds 
after  the  act  of  swallowing  (p.  56). 

Movements  of  the  Stomach. — The  inhibition,  which  precedes 
the  bolus,  spreads  to  the  entire  gastric  wall,  so  that  the  latter  is  now  in 

Cart/iuc  a/z/ri/Jti.  ^.^ ^ 


5^1 


ff//c/ular/s       W 
Py/or/r 


^/j//nmi   ',      <, 


Fig.  22. — Outlines  of  Normal  Stomach,  Resting. 

a  passive  condition  for  reception  of  the  food.  The  food  accumulates 
first  in  the  fundus  (Fig.  22).  This  arrangement  is  readily  compre- 
hended since,  as  was  shown  above,  there  is  normally  no  empty  space 
within  the  empty  stomach,  its  cavity  being  only  as  large  as  its  contents. 

Although  "appetite- juice"  is  present  already  in  the  stomach,  yet 
the  latter  remains  in  a  passive  condition,  movements  appearing  only 
after  the  expiration  of  about  30  minutes  from  the  beginning  of  the 
meal.  During  this  time,  and  probably  longer,  saHvary  digestion 
continues  undisturbed. 

The  food  ingested  remains  in  the  stomach  for  several  hours,  and 
is  ejected  at  intervals  into  the  duodenum.     Between  these  intervals, 


46 


PHYSIOLOGY  OF  DIGESTION 


the  food  is  isolated  in  the  stomach  from  the  rest  of  the  aUmentary 
tract  by  the  tonic  closure  of  the  sphincters  at  the  cardia  and  the  py- 
lorus. ^  The  portion  first  ingested,  lying  in  the  cardiac  portion,  is  marked 
oiT  from  the  antrum  by  a  strong  constriction  of  the  sphincter  antri  pylori. 
The  fundus  serves  as  a  reservoir  for  the  food,  and  is  subject  only  to  weak 
muscular  contractions.  The  pylorus,  on  the  contrary,  is  the  seat  of 
powerful  peristaltic  movements  by  means  of  which  the  food,  received 
from  the  passive  fundic  reservoir,  undergoes  thorough  churning  (Fig. 
23). 


Ificisi/ra  af/^z/^am 


Pif/oriis  Pe?-fsta/fir   co/z/rf/cfion 

Fig.  23. — Outlines  of  Normal  Stomach  Showing  Peristaltic  Contraction. 

After  the  lapse  of  about  30  minutes,  at  regular  intervals,  small 
peristaltic  waves  begin  somewhat  to  the  cardiac  side  of  the  sphincter 
antri  pylori,  and  push  the  food,  detached  from  the  surface  of  the  mass 
in  the  fundus,  into  the  antrum  pylori,  made  a  blind  pouch  by  the  clo- 
sure of  the  pylorus.  The  antrum  pjdori  now  becomes  lengthened,  and 
the  peristaltic  waves  here  increase  in  force  as  digestion   progresses. 

'  Fluids  ingested,  however,  even  when  the  stomach  already  contains  semisolid  food,  are 
rapidly  delivered  into  the  duodenum.  It  is  known  that  in  ruminants  the  regurgitated  and 
chewed  food  is,  when  again  swallowed,  delivered  directly  to  the  duodenum  by  means  of  a 
channel  which  is  temporarily  formed  along  the  lesser  curvature  of  the  stomach  by  contrac- 
tion of  the  gastric  musculature;  thus  this  thoroughly  masticated  food  is  kept  separate  from 
that  which  still  rests  in  the  saccular  stomachs  awaiting  its  turn  for  regurgitation  and 
rumination.  In  the  human  fetus  the  remains  of  such  a  canal  along  the  lesser  curvature 
may  be  recognized,  the  stomach  developing  as  a  pouched  dilatation  from  the  primitive 
foregut;  and  even  in  adults  the  gastric  musculature  is  so  arranged  as  to  provide  for  the 
temporary  segregation  of  a  tube  along  the  lesser  curvature,  which  serves  for  the  direct 
transmission  of  fluids  past  the  gastric  contents  into  the  duodenum.  This  canal  is  named  by 
Jefferson  (1915)  the  Canalis  gastricus.  Roentgenological  investigations  confirm  its  exist- 
ence. Jloreover,  only  by  some  such  mechanism  as  this  is  it  possible  to  e.xplain  the  pheno- 
menon of  selective  vomiting,  that  is  the  vomiting  of  some  fluid  such  as  bile  only,  whep  the 
stomach  is  full  of  food. 


MOVEMENTS    OF    THE    STOMACH  47 

The  pylorus  remaining  closed,  the  food  cannot  escape,  and  is  squeezed 
back  through  its  sole  outlet,  nanaely,  the  opening  in  the  advancing 
peristaltic  rings,  thus  forming  an  axial  reflux  stream  toward  the  cardiac 
end.  This  cycle  is  repeated  again  and  again,  until  the  hard  particles 
of  food  are  broken  up,  brought  into  close  contact  with  the  whole  of  the 
pyloric  mucous  membrane,  and  thoroughly  mixed  with  the  gastric 
juice. 

At  varying  periods  the  pyloric  orifice  relaxes,  and  a  few  cubic 
centimetres  of  chyme  are  squirted,  with  considerable  force,  into  the 
duodenum.  These  periods  vary  according  to  the  character  of  the 
ingesta,  the  carbohydrates  leaving  the  stomach  first,  the  fats  next,  and 
the  proteids  last.  The  relaxation  of  the  pylorus  becomes  more  fre- 
quent as  digestion  progresses.  When  gastric  digestion  is  over,  the 
pylorus  may  open  to  permit  the  passage  of  undigested  food-particles. 

The  duodenal  sphincter  described  by  Ochsner  may  aid  in  mixing 
the  chyme  just  received  from  the  stomach  with  the  duodenal  secretions 
and  prevent  its  too  early  escape  into  the  small  intestine. 

Opening  of  the  pylorus  is  brought  about  by  the  presence  of  free 
acid  in  the  stomach.  In  this  way,  the  acid  chyme  is  discharged  into  the 
the  duodenum.  The  presence  of  acid  in  the  duodenum,  on  the  con- 
trary, causes  contraction  of  the  pyloric  sphincter,  and  also  stimu- 
lates the  flow  of  the  alkaline  pancreatic  secretion.  Neutralization  of 
the  acid  in  the  duodenum  gradually  weakens  this  stimulus  to  pyloric 
closure,  so  that  the  cycle  is"  repeated  as  often  as  is  necessary  for  the 
emptying  of  the  stomach.  In  this  manner  the  intestine  is  charged 
with  food  very  gradually  by  the  stomach,  and  the  gastric  secretion, 
which  inhibits  the  action  of  intestinal  enzymes,  is  neutralized  in  small 
instalments. 

The  well-known  experiments  of  Kelling  (iQoo)  which  showed  that 
filling  of  the  duodenum  inhibited  contractions  of  the  stomach,  will  be 
referred  to  again  in  connection  with  gastro-jejunostomy  and  the  vicious 
circle. 

It  is  not  very  accurately  known  how  long  food  should  remain  in 
the  stomach  after  ingestion,  nor  how  soon  the  stomach  should  be 
found  empty.  Several  hours  at  least  must  elapse;  but  the  motor 
power  of  the  stomach  is  said  to  be  delayed  if  evidences  of  a  barium 
(or  other  opaque)  meal  are  found  in  the  stomach  on  roentgenological 
examination  6  hours  after  its  ingestion.  The  same  is  true  if  salol 
ingested  at  a  certain  hour  cannot  be  detected  in  the  urine  as  salicyluric 
acid  within  from  forty  to  sixty  (at  most  seventy-five)  minutes  (Ewald). 
Salol  is  not  absorbed  from  the  stomach,  but  by  means  of  an  alkaline 


48  PHYSIOLOGY  OF  DIGESTION 

reaction  in  the  duodenum.  \\'hen  a  drop  of  the  tincture  of  ferric 
chloride  is  added  to  filter  paper  moistened  with  urine  containing  sali- 
cyluric acid  a  dark  brownish  red  or  violet  color  is  produced. 

A  few  words  may  be  devoted  in  this  place  to  the  mechanism  of 
vomiting,  a  s\anptom  which  is  of  such  common  occurrence  in  diseases 
of  the  upper  abdomen  as  to  warrant  the  surgeon's  particular  attention. 
Vomiting  is  produced  largely  by  contraction  of  the  abdominal  muscles, 
acting  upon  a  fixed  diaphragm,  the  stomach  being  compressed  be- 
tween the  two.  No  doubt  the  stomach  itself  contracts  spasmodicalh' 
and  aids  in  the  ejection  of  the  food;  but  this  action  is  of  comparatively 
trivial  importance.  Sensory  impulses  to  the  gastric  mucosa  are  the 
chief  cause  of  vomiting,  although,  as  is  well  known,  certain  sights, 
certain  tastes,  and  irritation  of  the  uvula  or  the  pharynx  will  in  many 
persons  have  the  same  effect,  or  at  least  produce  nausea.  Sudden 
blockage  of  the  urinary  bladder  or  of  the  gall-bladder  by  a  calculus 
may  produce  the  same  result,  as  may  appendicular  colic. 

Movements  of  the  Small  Intestine. — The  small  intestine  presents 
two  kinds  of  movements,  the  rhythmical  or  pendular,  which  predominate, 
and  the  peristaltic. 

In  the  pendular  movements,  the  coils  of  gut  sway  from  side  to  side, 
and,  by  contractions  of  the  circular  musculature,  spht  the  column  of 
food  into  a  number  of  small  segments.  Soon  each  of  these  segments  is 
divided  in  half,  and  the  corresponding  halves  of  adjacent  segments 
re-unite.  This  process  is  repeated  again  and  again  at  the  rate  of 
20  times  a  minute.  Mall  likens  these  contractions  to  those  of  a  heart 
for  the  portal  circulation.  Once  or  twice  a  minute  the  segments  are 
carried  onward  a  certain  distance  by  an  advancing  peristaltic  wave,  and 
collected  into  a  new  mass.  Rhythmical  segmentation  again  occurs  in 
this  new  situation.  In  this  way  the  food  is  thoroughly  mixed  with  the 
digestive  secretions,  and  every  particle  is  brought  into  intimate  con- 
tact with  the  absorptive  walls,  since  with  each  constriction  the  mucous 
membrane  is  plunged  directly  into  the  midst  of  the  small  segments. 

The  peristaltic  movements  carry  the  unabsorbed  material  on- 
ward through  the  ileo-colic  sphincter  into  the  colon.  Regurgitation 
from  the  colon  into  the  ileum  is  prevented  by  the  tonic  contraction  of 
the  sphincter,  and  by  the  obliquity  of  the  ileo-cecal  valve. 

Movements  of  the  Large  Intestine. — The  presence  of  the  semi- 
fluid contents  in  the  colon  starts  up  anti-peristaltic  waves;  these  begin 
near  the  junction  of  the  ascending  and  the  transverse  colon,  at  which 
point  there  is  a  physiological  muscular  contracture  (corresponding  to 
the  ceco-colic  sphincter  of  the  lower  animals),  and  travel  slowly  toward 


MOVEMENTS    OF    THE    INTESTINES  49 

the  cecum,  carrying  the  food  into  the  latter.  Regurgitation  being 
impossible,  part  of  the  food  must  slip  back  in  the  axis  of  the  tube,  with 
the  same  effect  as  occurs  in  the  pylorus.  Sacculation  of  the  large  intes- 
tine heightens  the  efficiency  of  these  movements.  By  these  churning 
movements,  the  contents  of  the  gut  are  mixed  thoroughly  with  the 
enzymes  of  the  small  intestine,  and  well  exposed  to  the  actively 
absorbing  wall  of  the  large  intestine. 

Occasionally  a  true  peristaltic  wave,  excited  by  distention  of  the 
cecum,  and  initiated  in  the  latter  organ,  carries  the  food  to  the  trans- 
verse colon.  This  wave,  however,  soon  dies  away,  and  most  of  the 
food  is  carried  cecalward  again  by  the  anti-peristalsis.  As  the  as- 
cending and  transverse  colons  are  gradually  filled  with  food  from  the 
ileum,  and  as  absorption  proceeds,  the  drier  portions  accumulate 
toward  the  splenic  flexure,  where  they  are  probably  separated  from 
the  more  fluid  parts  by  transverse  waves  of  constriction,  and  eventually 
collect  in  the  omega  loop  and  rectum  as  feces. 

As  illustrative  of  the  interrelation  which  unites  the  digestive  proc- 
esses in  an  orderly  series  of  successively  dependent  events,  Cannon 
sums  up  as  follows: 

"Chewing  food  that  is  relished  starts  the  flow  of  gastric  juice; 
gastric  juice  in  the  duodenum  is  the  cause  of  flow  of  bile  and  the  pan- 
creatic secretion;  the  pancreatic  secretion  in  turn  stimulates  the  forma- 
tion of  kinase,  which  activates  the  trypsinogen.  Similarly,  on  the 
motor  side  of  digestive  activities,  the  presence  of  material  in  the  seem- 
ach  normally  starts  gastric  peristalsis;  acid  in  the  stomach  seems  to  be 
the  signal  for  the  opening  of  the  pylorus,  and  food  is  discharged; 
the  acid  food  in  the  duodenum  closes  the  pylorus  and  originates  seg- 
menting movements  to  churn  together  the  food,  pancreatic  juice,  and 
bile.  Peristalsis  carries  the  masses  forward;  now  in  new  situations 
their  presence  occasions  segmentation.  Finally,  the  remnant  of  the 
food  is  forced  from  the  ileum  into  the  colon;  and  each  new  accession 
to  the  accumulation  there,  is  followed  by  a  series  of  antiperistaltic 
waves  which  serve  to  abstract  still  further  the  valuable  constituents 
of  the  food.  When  a  certain  amount  of  useless  waste  has  gathered  in 
the  transverse  colon,  forward  peristaltic  waves  move  it  slowly  to  the 
rectum  to  be  discharged." 

Applied  Physiology. — Above,  we  have  given  a  brief  account  of 
the  secretory,  absorptive,  and  motor  activities  of  the  gastro-intestinal 
tract.  Let  us  see  what  practical  application  can  be  made  of  these  facts. 
In  other  woods,  let  us  consider  briefly  the  subject  of  applied  physiology. 

In  the  first  instance,  attention  has  already  been  directed  to  the 


50  PHYSIOLOGY  OF  DIGESTION 

importance  of  a  good  set  of  teeth.  Here,  at  the  very  entry  to  the  gastro- 
intestinal tract,  is  a  necessary  set  of  organs,  the  integrity  of  which 
is  essential  to  secure  the  best  results  from  digestion.  Yet  too  often 
the  teeth  are  found  incomplete  in  number,  or  the  seat  of  varying 
degrees  of  decay.  There  is  small  wonder  for  this,  not  only  because  in 
the  human  race  the  teeth  are  undergoing  inherited  retrograde  pro- 
cesses due  to  unnatural  preparation  of  foods,  but  also  because  the 
dental  organs  are  subjected  to  the  action  of  the  oral  micro-organisms 
and  their  products,  as  lactic  acid.  Hence,  we  believe  the  teeth  should 
be  put  in,  and  kept  in,  the  best  condition  possible. 

The  importance  of  sterilizing  the  mouth  as  far  as  possible,  and  the 
food  that  enters  it  in  the  preliminary  preparations  for  operations  on 
the  stomach,  is  known  to  all  cUnicians.  So,  too,  is  the  regard  for  the 
teeth  in  the  administration  of  hydrochloric  acid. 

The  stomach  is  worthy  of  more  attentive  care  than  it  usually  gets. 
It  is  not  just  to  dispose  of  it,  from  a  physiological  standpoint,  lightly 
as  a  mere  convenience  for  the  storage  of  food.  The  bladder  and  the 
rectum,  if  one  wish,  may  be  considered  as  convenient  reservoirs, 
but  it  must  be  remembered  that  these  organs  are  the  terminals  for, 
respective^,  the  urinary  and  the  digestive  apparatus,  and  they  have 
no  other  function  than  that  of  storage.  The  stomach,  on  the  contrary, 
is  at  the  very  portals  of  the  digestive  tube.  Not  only  does  it  possess 
definite  enzymotic  and  motor  functions,  but  it  is  also  a  sensitive 
organ,  endowed  with  selective  powers,  in  that  it  retains  wholesome 
food,  and  rejects  that  which  is  detrimental  or  injurious.  That 
the  stomach  is  one  of  the  most  sensitive  organs  in  the  body  cannot  be 
denied,  and  it  is  equally  true  that  for  this  reason,  if  for  no  other,  it 
should  receive  much  consideration,  like  other  sensitive  things.  Situ- 
ated between  the  harmful  objects,  bacterial,  chemical,  and  physical, 
of  the  outside  world  and  the  delicate  intestines,  it  exercises  a  dis- 
tinct protective  function  over  the  gut.  But  it  is  a  mistake  to  consider 
the  stomach,  or  any  other  part  of  the  gastro-intestinal  tract,  as  a  sep- 
arate and  distinct  entity.  Its  embryological  and  physiological  rela- 
tions forbid  this,  and  this  is  equally  true  of  the  other  bodily  systems, 
such  as  the  nervous,  the  respiratory,  the  circulatory,  and  the  urinary. 
The  intimate  functional  inteirelations  of  the  various  portions  of  the 
gastro-intestinal  tract  have  been  noted,  and  these  inter-relations  operate 
not  only  physiologically,  but  pathologically.  Were  it  of  any  avail, 
we  should  further  decry  abuse  of  the  stomach.  We  demand,  however, 
that  it  receive  consideration  solely  in  conjunction  with  the  remainder 
of  the  system  with  which  it  is  correlated. 


.APPLIED    PHYSIOLOGY  5 1 

The  great  value  the  appetite  holds  in  the  interests  of  the  economy 
cannot  be  overestimated.  Like  other  instincts,  it  cannot  be  neglected 
with  impunity.  To  restore  appetite  to  a  sickly  patient  is  to  confer 
upon  him  a  boon,  the  effects  of  which  are  far-reaching.  Not  the  least 
of  these  is  the  preservation  of  the  integrity  of  the  body  by  enriching 
the  blood,  thereby  increasing  the  protective  and  defensive  powers  of 
the  organism. 

In  the  first  instance,  regular  hours  for  the  intake  of  food  are  as  im- 
portant as  for  the  ejection  of  the  residue  from  the  body.  Food  should 
not  be  gobbled,  but  should  be  well  masticated,  and  eaten  with  dis- 
crimination and  care.  To  secure  the  best  results,  the  attention  should, 
as  far  as  possible,  be  concentrated  upon  the  process  of  ingestion.  The 
degree  of  enjoyment  with  which  food  is  taken  is  enhanced  by  the 
attractiveness  with  which  it  is  prepared.  Furthermore,  the  patient's 
tastes  should  receive  due  consideration. 

Even  should  these  conditions  be  fulfilled,  appetite,  and  conse- 
quently, appetite-juice,  may  still  be  absent.  In  this  instance,  feeding 
would  be  forced;  such  a  method  is  unnatural,  and  frequently  the 
stomach  rebels  against  it.  Here  the  aim  should  be  to  restore  the 
appetite,  for  this  means  copious  secretion  of  gastric  juice  to  act  upon 
the  ingesta.  It  often  is  wise  to  administer  a  cup  of  beef-broth  shortly 
before  meal-time,  for  both  the  water  and  the  beef-extract  contained 
therein  are  undoubtedly  strong  excitants  of  gastric  juice.  In  the 
same  way,  suitable  doses  of  hydrochloric  acid  may  be  carefully  given, 
since  acids  are  specific  stimuli  to  the  pancreas.  Further,  it  is  often 
beneficial  to  order  food  in  small  quantities,  frequently  repeated.  By 
this  method,  too  much  work  is  not  thrust  suddenly  upon  a  stomach 
impaired  in  its  activity,  and  appetite-juice,  which  is  so  powerful,  is 
repeatedly  called  forth. 

For  patients  in  whom  the  sense  of  taste  is  impaired,  bitters  may 
be  found  very  useful.  Not  only  do  these  stimulate  the  gustatory  cells 
by  means  of  contrast  to  pleasant  sensations,  but  also  they  produce  a 
certain  psychic  effect,  and  this,  in  turn,  indirectly  excites  a  physiological 
secretory  activity. 

Milk  is  a  rational  food  for  the  sick,  in  that  it  nourishes  the  organism 
with  the  least  degree  of  work  on  the  part  of  the  digestive  tract,  since  it 
provokes  the  weakest  gastric  juice  and  the  smallest  amount  of  pan- 
creatic fluid,  and  hence  gives  these  organs  rest.  This  rest  is  very 
desirable  when  the  gastric  glands  manifest  excessive  activity.  Alka- 
lies, also,  exert  an  inhibitory  influence  upon  the  digestive  glands.  The 
value  of  large  doses  of  sodium  bicarbonate  in  hyperchlorhydria  is  well 


52  PHYSIOLOGY  OF  DIGESTION 

known.  It  reduces  the  secretion  in  the  stomach,  and,  by  diminishing 
the  activity  in  this  organ,  restrains  the  activity  of  the  pancreas.  On 
the  other  hand,  when  administered  in  small  doses,  this  salt,  theoretic- 
ally from  a  chemical  standpoint,  calls  forth  an  increased  output  of 
hydrochloric  acid. 

Just  -as  any  irritating  substance,  bacterial,  physical,  or  chemical 
evokes  hypersecretion  from  any  mucous  or  serous  surface,  so  does  it 
from  the  very  extensive  mucous  membrane  of  the  gastro-intestinal 
tract.  This  overproduction  of  mucus  is  protective  in  nature,  in  that 
it  comes  from  the  surface  epithelium,  and  thus  wards  off  the  danger 
that  threatens  the  more  important  elements  of  the  mucous  mem- 
brane beneath.  Therefore,  many  forms  of  diarrhea  are  expressive  of 
defence  on  the  part  of  the  organism. 

In  the  same  way.  defensive  activities  in  the  peritoneal  cavity  are 
carried  out  by  the  omentum  upon  the  serous  tunic  of  the  intestines. 
Thus,  the  omentum  is  a  most  important  agent  in  developing  phago- 
cytosis and  opsonins;  its  germinating  endothelium  is  constantly 
producing  lymphocytes  and  is  capable,  under  proper  stimulation,  of 
throwing  both  newly  formed  phagocytes  and  those  called  from  a 
distance  into  germicidal  action.  This  wiping  process  is  greatly  aided 
by  the  vermicular  and  swaying  movements  of  the  intestines,  which, 
in  spite  of  gravity,  bring  all  parts  of  the  wall  of  the  small  gut  in  contact 
with  the  omentum,  the  epiploic  tags  having  the  same  function  for  the 
more  fixed  large  intestine. 


CHAPTER   III 
SURGIC\L  DISEASES  OF  THE  STOMACH  AND  DUODENUM 

General  Diagnostic  Considerations 

Although  the  diagnosis  of  each  surgical  affection  is  discussed  in 
the  special  chapter  devoted  to  the  subject,  yet  it  is  convenient  in  this 
place  to  dwell  upon  certain  general  considerations.  And  we  do  this 
with  the  greater  confidence,  because  we  fear  that  some  surgeons  who 
are  called  in  merely  as  consultants  may  be  tempted  to  take  the  diag- 
nosis of  the  malady  ready  made  from  the  physician  and  to  regard  the 
operative  treatment  of  their  patients  as  the  only  province  particularly 
belonging  to  surgery.  This  attitude  of  mind,  we  venture  to  suggest, 
is  not  only  derogatory  to  the  profession  of  surgery,  but  inimical  to  the 
ultimate  interests  both  of  patient  and  surgeon.  While  we  realize 
that  all  progressive  physicians  are  now  anxious  to  have  a  surgical 
consultation  in  the  case  of  most  of  the  diseases  of  the  upper  abdomen 
which  do  not  readily  yield  to  hygienic  and  dietetic  measures,  we  are 
also  well  aware  that  they  are  loath  to  consult  a  surgeon  who  can  offer 
no  other  advice  than  to  adopt  the  plan  which  is  colloquially  referred 
to  as  "  taking  off  the  lid."  It  is  admitted  by  all  that  it  is  desirable  for 
the  surgeon  to  have  a  thorough  appreciation  of  the  natural  course  of 
the  morbid  process  going  on  within  the  patient,  in  other  words,  that 
he  must  be  well  grounded  in  the  pathology  of  these  diseases;  but  it  will 
be  impossible  for  him  to  give  an  intelligent  opinion  on  such  questions, 
unless  he  is  first  abe  to  determine  what  the  disease  really  is.  To  put 
it  in  the  plainest  terms,  a  consultant  must  be  able  to  render  an  opinion 
which  will  be  worth  the  asking;  and  unless  his  diagnostic  acumen  is  of 
the  highest,  physicians  will  soon  perceive  that  it  is  for  their  patients' 
interest  to  go  elsewhere. 

Anamnesis. — In  every  case,  there  is  no  surer  foundation  on  which 
to  lay  the  facts  which  go  to  make  up  a  correct  diagnosis,  than  an  ac- 
curate and  complete  history  of  the  patient's  past  medical  life  and 
present  complaint.  It  is  e.xceptional  indeed  for  such  a  history  not  to 
point  the  way  toward  further  investigations  which  will  reveal  the 
true  malady.  It  may  seem  tedious  and  commonplace  both  to  patient 
and  surgeon  to  lay  stress  on  data  such  as  occupation,  general  habits 

S3 


54  SURGICAL  DISEASES  OF  THE   STOMACH  AND  DUODENUM 

of  diet,  previous  illnesses,  etc.;  but  neglect  of  one  minor  detail  may 
distort  the  clinical  picture,  and  lead  the  diagnostician  very  seriously 
astray. 

Cross-examination,  and  even  a  re-direct  examination  is  in  many 
cases  essential  to  establish  the  truth  of  the  patient's  story. 

In  addition  to  the  patient's  history,  the  careful  diagnostician  will 
take  advantage  of  every  fact  that  may  be  learned  from  a  complete 
physical  examination,  including  Inspection,  Palpation,  Percussion,  and 
Auscultation;  Alensnration  also  may  be  of  value  in  a  few  instances. 
Nor  should  laboratory  aids  be  despised  (p.  57).  Skiagraphy  as  an 
aid  to  diagnosis  is  discussed  at  page  61. 

Inspection.- — The  patient  should  lie  fiat  on  the  back,  with  the 
entire  abdomen  and  lower  thorax  bared,  and  in  a  good  light.  The 
general  contour  of  the  abdomen  should  be  noted,  whether  fat  or 
emaciated,  tense  or  flaccid;  together  with  the  presence  or  absence  of 
localized  bulging,  of  peristaltic  waves,  of  scars  from  previous  opera- 
tions, etc.  Attention  should  be  directed  to  the  character  of  the 
breathing,  whether  it  be  natural  or  affected  by  the  surgeon's  examina- 
tion. The  appearance  of  the  costal  angle  should  be  noted,  as  well  as 
any  undue  bulging  or  depression  of  the  pit  of  the  stomach.  The  con- 
figuration of  the  thorax,  as  indicative  of  tight  lacing,  may  prove  of 
diagnostic  value  in  certain  affections  of  the  liver  and  stomach. 

Palpation.^ — This  is  the  most  valuable  of  all  means  of  physical 
examination  at  the  command  of  the  surgeon.  It  should  never  be 
omitted,  and  should  always  follow  inspection.  In  order  to  obtain  the 
greatest  number  of  diagnostic  points  by  its  means,  it  is  important  to 
have  the  abdominal  muscles  as  relaxed  as  possible.  This  relaxation . 
is  best  secured  by  having  the  patient's  head  and  shoulders  slightly 
elevated,  and  by  flexing  the  thighs  on  the  abdomen.  The  thighs 
should  be  passively,  not  actively,  flexed;  so  that  it  is  best  either  to 
support  the  knees  by  placing  a  pillow  beneath  them,  or  to  have  the 
thighs  flexed  so  far  that  the  soles  of  the  feet  will  rest  comfortably  on 
the  bed  or  couch  on  which  the  patient  lies. 

The  hands  of  the  diagnostician  should  be  warm,  so  that  no  reflex 
spasm  of  the  abdominal  muscles  will  be  caused  by  chilling  from  contact 
of  the  hands.  It  should  be  an  invariable  rule  to  begin  the  palpation 
in  some  presumably  healthy  region  of  the  abdomen,  in  order  to  accus- 
tom tlie  patient  to  the  palpating  hand  before  the  diseased  area  is 
reached,  and  to  ascertain,  if  possible,  the  natural  condition  of  the  beUy 
wall  in  health.  The  patient's  attention  may  be  diverted  from  the 
local  examination  by  conversation.     The  entire  abdomen  should  be 


GENERAL   DIAGNOSTIC   CONSIDERATIONS  55 

thoroughly  examined  by  palpation,  the  hand  being  allowed  to  slide 
over  its  surface  rather  than  being  raised  and  again  laid  on  the  skin, 
for  fear  of  producing  involuntary  contraction  of  the  abdominal  muscles 
from  the  new  contact. 

The  degree  of  rigidity  in  all  portions  of  the  abdomen  must  be 
noted.  Attentive  examination  should  be  made  of  any  rumor  detected, 
noting  especially  its  location,  its  consistence,  its  general  conformation, 
its  mobility,  and  if  any,  in  what  direction;  the  presence  or  absence  of 
movement  during  respiration;  and  finally  its  relation  to  surrounding 
structures  must  be  considered. 

The  degree  of  tenderness  present  in  the  various  portions  of  the 
abdomen  must  be  noted,  together  with  the  amount  of  pressure  neces- 
sary to  provoke  it.  The  degree  of  tenderness  to  pressure,  combined 
with  the  rigidity  of  the  abdominal  wall  at  the  site  of  the  tenderness, 
will  often  be  of  marked  diagnostic  significance. 

The  presence  or  absence  of  a  succussion  splash  in  the  stomach  may 
be  determined  by  means  of  palpation.  This  splash  is  very  significant 
in  cases  of  gastrectasis  if  found  in  certain  relation  with  meals,  as  it  will 
indicate  decided  lack  of  gastric  motility. 

Percussion. — This  is  of  the  utmost  value  in  mapping  out  the  rela- 
tion of  the  various  abdominal  organs.  It  will  reveal  the  size  and  posi- 
tion of  the  liver,  the  position  of  the  colon,  of  the  stomach,  and  of  the 
spleen;  the  presence  or  absence  of  hepatic  dullness;  the  presence  or 
absence  of  free  fluid  in  the  abdominal  cavity,  etc.  In  many  instances 
much  additional  information  is  to  be  gained  by  distending  the  stomach 
with  air  or  liquid,  so  that  its  position  and  extent  can  be  definitely 
determined.  The  stomach  may  readily  be  filled  with  water  by  drink- 
ing; this  method  is  so  extremely  simple  that  it  often  is  overlooked. 
Air  may  be  forced  into  the  stomach  by  means  of  a  hand  bulb  on  the 
stomach  tube;  we  do  not  approve  of  the  use  of  an  effervescing  powder 
for  inflation  of  the  stomach,  because  this  latter  method  cannot  be  con- 
trolled, and  may  lead  to  serious  results;  moreover,  it  certainly  causes 
much  more  discomfort  to  the  patient  than  does  the  use  of  a  stomach 
tube,  by  means  of  which  the  amount  of  air  introduced  can  be  accurately 
regulated.  The  patient  himself  is  the  best  judge  of  the  amount  of  air 
to  be  introduced;  and  the  least  discomfort  on  his  part  should  make  the 
surgeon  desist  from  introducing  more  air.  The  same  is  true  for  the 
introduction  of  fluids,  either  for  the  purpose  of  distending  the  stomach, 
or  for  washing  it  out.  If  any  doubt  as  to  the  outlines  of  the  stomach 
remains  after  distention  with  air  or  fluid  has  been  tried,  it  is  at  times 
advisable  to  inflate  the  colon  with  air  while  the  stomach  is  distended 


56  SURGICAL  DISEASES  OF  THE  STOiMACH  AND  DUODEN'Uil 

with  fluid.  In  this  way  percussion  will  reveal  their  relati\-e  positions 
with  great  accuracy,  and  may  throw  much  light  on  an  obscure  condi- 
tion, or  reveal  the  exact  location  of  any  tumor  that  may  be  present. 

Auscultation. — Auscultation  alone,  or  in  combination  with  per- 
cussion, may  be  of  decided  value  in  the  diagnosis  of  diseases  of  the 
upper  abdomen.  It  is  well  known  that  the  time  when  food  or  hquids 
enter  the  stomach  can  be  detected  by  auscultating  the  thora.v  about 
three  inches  below  the  angle  of  the  left  scapula.  It  is  well  for  the 
inexperienced  to  listen  to  the  normal  sound  in  healthy  individuals, 
many  times,  before  attemping  to  diagnosticate  a  lesion  of  the  esoph- 
agus or  cardia  by  this  method.  The  amphoric,  rushing  sound  is  heard 
from  three  to  seven  seconds  after  the  act  of  swallowing:  if  delayed 
more  than  ten  seconds,  it  is  safe  to  infer  that  some  obstruction,  spas- 
modic or  organic,  is  present. 

Auscultatory  percussion  is  sometimes  of  aid  in  determining  the 
exact  outlines  of  a  distended  stomach.  In  a  similar  manner,  the  coin 
test  may  be  used  in  the  case  of  an  air-containing  cavity,  such  as  the 
stomach,  or  in  that  of  a  subphrenic  abscess  in  direct  connection  with  the 
gastro-intestinal  tract. 

Mensuration. — This  is  occasionally  useful  to  record  from  time 
to  time  variations  in  the  amount  of  abdominal  distention;  to  note 
increase  of  ascitic  fluid ;  to  compare  one  side  of  the  abdomen  with 
the  other,  etc.  Hoover's  test  for  subphrenic  abscess  is  described  at 
p.  408. 

General  Health. — In  deciding  for  or  against  an  operation  it  is 
of  course  requisite  for  the  surgeon  to  take  into  consideration  the  general 
health  of  the  patient.  The  state  of  the  heart,  the  lungs,  and  the . 
vascular  system  should  be  attentively  studied;  and  careful  examina- 
tion should  be  made  of  the  amount  and  quality  of  the  urine  excreted. 
Myocardial  disease  will  be  in  general  more  of  a  contraindication  to 
operation  than  will  a  well  compensated  valvular  lesion.  High  blood 
pressure  is  by  no  means  a  contraindication  to  an  otherwise  necessary 
operation;  but  this  factor,  as  well  as  the  renal  functions  as  determined 
by  the  phenolsulphonephthalein  test  are  of  great  value  in  prognosis, 
and  of  much  importance  in  the  choice  of  an  anesthetic.  The  gastric  and 
intestinal  manifestations  of  nephritis  should  be  kept  constantly  in  mind. 

Gastric  Analysis. — Chemical  analysis  of  the  gastric  secretion,  and 
determination  of  the  motor  functions  of  the  organ,  sometimes  are  of  aid 
in  reaching  a  correct  diagnosis. 

The  motor  function  of  the  stomach  is  best  tested  by  means  of  the 
fluoroscope  (p.  64).     If  this  is  impossible,  the  stomach  may  be  evacu- 


GENERAL   DIAGNOSTIC   CONSIDERATIONS  57 

ated  by  the  stomach  tube  about  twelve  hours  after  the  ingestion  of  an 
ordinary  full  meal.  It  is  better,  as  advised  by  Paterson,  to  give  a 
definite  quantity  (12  oz.,  or  340  cc.)  of  milk  on  an  empty  stomach  and  to 
evacuate  the  stomach  exactly  ten  hours  later.  It  is  convenient  to  give 
some  raisins  with  the  milk,  as  the  skins  are  readily  recognized  if  re- 
covered. If  food-remains  are  recovered  it  indicates  pyloric  stenosis  or 
motpr  insufficiency.  Any  amount  even  up  to  400  cc.  may  be  recovered. 
If  no  food-remains  arc  found,  there  is  no  pyloric  stenosis.  If  acid  fluid 
without  food-remains  is  recovered,  this  is  an  indication  of  hypersecre- 
tion, which  occurs  in  duodenal  ulcer,  without  pyloric  stenosis,  as  well  as 
in  many  cases  of  chronic  appendicitis,  and  in  a  few  cases  of  gastric  ulcer. 

For  purposes  of  chemical  analysis  a  uniform  test  meal  should  be  em- 
ployed. The  usual  test  meal  (Ewald's)  consists  of  one  or  two  slices 
(60  grammes)  of  toast  and  a  cup  (250-400  cc.)  of  weak  tea,  with  sugar 
but  without  milk.  Whatever  the  nature  of  the  meal,  it  cannot  too 
strongly  be  emphasized  that  it  should  be  given  on  an  empty  stomach 
(as  for  instance  just  after  lavage  to  test  the  gastric  motor  functions) 
and  that  it  should  be  constant  in  amount  and  quality  if  the  results  of  the 
analysis  are  to  be  compared  with  those  obtained  in  other  cases.  The 
stomach  contents  are  drawn  off  e.xactly  one  hour  after  the  patient 
began  to  eat  his  test  meal.  The  amount  normally  recovered  is  from 
100  to  140  cc.  If  there  is  stenosis  this  amount  may  reach  even  to 
500  or  600  cc.  If  the  case  is  one  of  duodenal  ulcer,  often  less  than  the 
normal  amount  is  recovered. 

It  is  not  worth  while  in  a  work  of  this  kind  to  go  into  any  detailed 
statement  of  the  chemical  tests  in  common  use  in  gastric  analysis.  A 
summary  of  the  usual  findings,  however,  may  be  of  use.  These  we 
have  condensed  from  Paterson's  valuable  monograph  on  the  Surgery 
of  the  Stomach. 

Free  hydrochloric  acid  is  present  in  duodenal  or  pyloric  ulcer,  in 
gall-bladder  diseases,  and  sometimes  in  chronic  appendicitis.  It  is 
absent  in  malignancy,  in  severe  chronic  gastritis,  in  hour-glass  stomach, 
and  usually  in  chronic  appendicitis. 

Lactic  acid  is  almost  always  present  in  small  amount  after  the 
ordinary  test  meal.  Only  if  present  after  a  special  (Boas)  test  meal, 
is  its  presence  significant:  At  night  wash  the  stomach  absolutely  clear. 
Next  morning  wash  it  again,  and  then  give  oatmeal  soup  (one  table- 
spoonful  of  rolled  cats  in  1000  cc.  of  water,  boiled  down  to  500  cc,  to 
which  is  added  a  little  milk  but  no  salt).  Two  hours  later  draw  off  the 
stomach  contents,  filter,  and  test  for  lactic  acid  with  Uffelmann's 
reagent.     Under    such    circumstances    lactic    acid    is    rarely    present 


58  SURGICAL  DISEASES  OF  THE  STOMACH  AND  DUODENUM 

except    in    gastric   carcinoma.     A    positive  test  therefore  is  of  great 
significance. 

The  total  acidity  fHCl,  volatile  acids,  and  acid  phosphates)  of 
the  gastric  juice  varies  in  health  between  55  and  65;^  a  figure  over 
70  is  regarded  as  hyperacidity,  and  one  under  50  as  hypoacidity. 
Hyperacidity  should  not  be  confused  with  hyperchlorhydria:  as  the 
total  acidity  is  contributed  to  by  HCl,  by  volatile  acids,  and  by  acid 
phosphates,  hyperacidity  may  be  due  to  an  increase  of  any  or  all 
of  these  constituents.  Hyperchlorhydria  implies  an  increase  solely  in 
the  hydrochloric  acid. 

The  amount  of  free  HCl  normally  varies  from  0.018  to  0.022, 
the  average  being  0.020.- 
In  duodenal  ulcer  it  is  increased. 
In  gastric  (pyloric)  ulcer  it  is  increased. 
In  pyloric  stenosis  it  is  decreased. 
In  gastric  ulcer  which  has  cicatrized  or  which  is  in  the  body 

of  the  stomach,  it  is  decreased. 
In  hour  glass  stomach  it  is  decreased. 
In  carcinoma  it  is  absent. 

In  chronic  appendicitis  it  is  decreased  or  absent. 
The  amount  of  total  chlorides  normally  varies  from  0.310  to 
0.330,  the  average  being  0.320. 
In  duodenal  ulcer  there  is  a  very  marked  increase. 
In  gastric  ulcer  there  is  usually  a  moderate  increase,  especially 

if  the  ulcer  is  near  the  pylorus. 
In  carcinoma  it  is  decreased. 
In  pyloric  stenosis  it  is  usually  decreased. 
In  chronic  appendicitis  it  may  be  increased  or  decreased, 
usually  decreased. 
The  amount  of  the  volatile  acids  normally  varies  from  2  to  5. 
In  gastric  ulcer  there  is  no  change. 
In  duodenal  ulcer  usually  there  is  no  change. 
In  carcinoma  usually  an  increase. 
In  chronic  appendicitis  usually  an  increase. 

'  That  is,  it  requires  from  55  to  65  cc.  of  decinormal  sodium  hydroxide  solution  to 
neutralize  the  aciditj'  in  100  cc.  of  gastric  contents. 

*  Recent  investigations  by  Boldyreflf  (1914)  tend  to  demonstrate  that  the  real  acidity  of 
fresh  gastric  juice  is  equivalent  to  0.5  %  HCl,  much  the  same  as  in  dogs;  but  as  usually 
obtained  in  man  it  has  been  neutralized  in  part  automatically  by  reflux  of  alkaline  duodenal 
secretions,  and  in  part  by  the  test  meal  administered.  This  raises  the  question  whether 
"clinical  hyperacidity"  may  not  be  due  to  loss  of  duodenal  reflux  rather  than  to  a  patho- 
logical state  of  the  gastric  juice. 


GENER.A.L    DI.-VGNOSTIC    CONSIDERATIONS 


59 


The  amount  of  the  protem  hydrochloric  acid  normally   varies 
from  0.220  to  0.250. 
In  carcinoma  it  is  very  markedly  diminished,  usually  less  than 

o.ioo. 
In  other  conditions  it  is  of  no  significance. 

The  amount  of  the  mineral  chlorides  is  very  markedly  increased  in 
carcinoma  (the  free  HCl  probably  is  fixed  by  the  alkaline  secretion 
from  the  growth) . 

The  following  table,  adapted  from  Paterson's,  gives  certain  typical 
gastric  analyses: 

Typical  Gastric  Analyses 


Lesion 

Total 
acidity 

Total 
chlorides 

Free 
HCl 

Protein 
HCl 

Mineral 
chlorides 

82 
80 

0.350 
0.40s 

0.038 
o.oss 

0.229 
0.27s 

0.080 

0.075 

Gastric  ulcer  fDvloric) 

7S 
78 
70 

0-32S 
0.308 

0-332 

0.040 
0.025 
0.000 

0.20s 
0.206 
0.230 

0.080 

0.077 

0.098 

28 

0.178 

0.000 

0.0s  I 

0. 124 

ADDcndicular  ffastralcria     .    . 

61 

0.288 

0.007 

0.201 

0.080 

Normal  Average 

60 

0.320 

0.020 

0-235 

Passing  the  Stomach  Tube. — The  stomach  tube  should  be  in 
good  condition,  and  its  surface  should  be  perfectly  smooth.  As  soon 
as  the  surface  begins  to  crack,  the  tube  should  be  discarded.  The 
tube  should  be  cleansed  and  boiled  after  using;  it  should  then  be  dried 
in  the  air  and  put  away.  It  is  not  necessary  to  boil  it  again  just  before 
using,  though  it  is  often  desirable  to  do  so;  but  repeated  boiHng  soon 
destroys  it.  The  tube  should  be  marked  about  40  or  45  cm.  from  its 
extremity,  and  when  introduced  this  mark  should  correspond  to  the 
patient's  teeth.  The  esophagus  begins  about  15  cm.  from  the  dental 
margin  and  is  about  25  cm.  in  length.  When  the  tube  is  to  be  used  as  a 
pump  it  should  have  a  hand  bulb  attached  to  it  about  25  cm.  beyond  the 
"tooth  mark."  If  the  delivery  tube  is  pinched  in  the  fingers  close  to 
the  bulb,  pressure  on  the  bulb  will  force  its  contained  air  into  the 
stomach;  this  air  will  be  held  in  the  stomach  by  pinching  the  stomach 
tube  as  the  bulb  is  allowed  to  expand.     Air  will  escape  spontaneously 


6o 


SURGICAL  DISEASES  OF  THE  STOMACH  AND  DUODENUM 


from  the  inflated  stomach,  through  the  tube,  as  soon  as  the  bulb  is 
detached.  To  withdraw  fluid  from  the  stomach,  syphonage  will  usu- 
ally suffice;  but  by  reversing  the  maneuvres  above  described,  the  appa- 
ratus may  be  converted  into  a  suction  pump  (Fig.  24). 

If  the  patient  is  strong  enough,  it  is  more  convenient  to  pass  the 
tube  while  he  is  in  a  sitting  posture;  if  necessary,  however,  it  is  quite 
possible  to  introduce  it  while  he  is  lying  down.     In  most  cases  sufil- 


FiG.   24. — Diagram  of  the  Stomach  Tube  in  situ. 

cient  lubrication  will  be  afTorded  by  the  mucus  in  the  pharynx  and 
esophagus,  the  tube  being  chilled  by  being  laid  in  a  basin  failed  with 
ice-water  just  before  being  introduced.  Oils  or  other  lubricants  are 
usually  very  disagreeable  to  the  patient.  A  mouth  gag  need  not  be 
employed  except  in  children  and  unconscious  or  refractory  patients. 

The  surgeon,  facing  the  patient,  and  having  his  own  clothing,  as 
well  as  that  of  the  patient,  suitably  protected,  takes  the  stomach  tube, 
about  six  inches  from  its  end,  in  his  right  hand,  holding  it  as  a  pen; 
then,  directing  the  patient  to  open  the  mouth  widely,  he  passes  the 


GENERAL   DIAGNOSTIC   CONSIDERATIONS  6 1 

index  finger  of  his  left  hand  into  the  patient's  mouth.  With  the 
left  forefinger  as  a  guide,  and  drawing  forward  on  the  base  of  the 
tongue,  the  stomach  tube  is  gently,  but  firmly  passed  back  until  its 
end  touches  the  posterior  wall  of  the  pharynx.  By  then  guiding  its 
point  downward  with  the  left  index  finger,  it  is  gradually  fed  onward 
by  the  right  hand;  and  by  keeping  it  close  against  the  posterior  pharyn- 
geal wall,  it  will  glide  into  the  esophagus.  At  this  moment  the  patient, 
if  the  stomach  tube  is  being  passed  for  the  first  time,  usually  gags, 
and  feels  as  though  he  were  smothering.  If  he  is  assured,  however, 
that  all  is  going  well,  his  momentary  distress  is  quieted,  and  if  he  takes 
deep  breaths  and  swallows  frequently  the  tube  will  glide  down  into  the 
stomach,  until  the  tooth  mark  reaches  the  dental  margin.  It  is  very 
seldom  that  force  is  required,  when  once  the  end  of  the  tube  has  become 
fairly  engaged  in  the  esophagus;  and  if  the  surgeon  is  gentle  and  patient 
in  his  manipulations,  the  patient  will  find  that  the  ordeal  of  having  a 
stomach  tube  passed  is  by  no  means  unbearable;  indeed  that  it  is 
much  less  disturbing  in  reality  than  in  anticipation. 

After  a  patient  has  had  a  tube  passed  once  or  twice,  no  guiding 
finger  will  be  necessary,  and  the  patient  very  often  will  prefer  to  pass 
it  himself,  instead  of  having  this  done  by  the  surgeon.  Those  who 
are  in  the  habit  of  having  stomach  tubes  passed  experience  very  little 
more  discomfort  than  is  felt  in  passing  a  soft  rubber  catheter  through 
a  normal  urethra. 

Lavage  of  the  Stomach. — Tepid  water,  either  alone,  or  with  a 
httle  bicarbonate  of  soda  added,  is  the  liquid  that  is  usually  employed. 
For  patients  with  marked  fermentative  changes,  a  weak  solution  of 
permanganate  of  potassium  is  useful.  Not  more  than  250  to  300  cc. 
should  be  passed  into  the  stomach  at  first.  This  should  be  done  very 
gradually,  with  the  funnel  of  the  tube  very  little  higher  than  the  level  of 
the  stomach.  The  feeling  of  beginning  discomfort  on  the  patient's  part 
is  the  safest  indication  of  the  amount  to  be  introduced  at  one  time. 
In  unconscious  patients,  and  in  those  with  marked  disease  of  the 
stomach,  only  a  very  small  quantity  should  be  used  at  any  one  time; 
and  even  greater  gentleness  than  usual  should  be  employed,  on  account 
of  the  danger  of  producing  rupture  of  the  stomach  (see  p.  297).  After 
the  proper  amount  has  been  introduced  into  the  stomach,  the  funnel 
should  be  lowered  and  then  inverted  over  a  waste  bucket,  and  the  gastric 
contents  syphoned  off,  the  process  being  repeated  until  the  iiuid  returns 
clear. 

The  X-rays  in  Diagnosis  of  Lesions  of  the  Upper  Abdomen. 
In  cases  where  the  clinical  history  and  ordinary  methods  of  physical 


62 


SURGICAL  DISEASES  OF  THE  STOMACH  AND  DUODENUM 


examination  leave  the  diagnosis,  in  doubt,  or  where  it  is  desired  to  ob- 
tain confirmation  of  diagnosis,  roentgenology  often  will  be  of  mate- 
rial assistance.  There  is  but  one  objection  to  the  use  of  the  X-ray  in 
this  connection,  and  this  is  the  fact  that  it  is  useless  unless  employed  by 
an  expert  in  this  particular  branch  of  X-ray  work.  The  technique 
employed  is  so  complicated,  and  demands  such  close  study,  that  a 
description  of  it  would  be  entirely  out  of  place  here;  but  it  is  necessary 
for  the  clinician  who  is  to  take  advantage  of  work  being  done  by  ex- 


^ii,^*^ 


Fig.    25. — -Normal    Peristalsis,    Resembling   Indurated    Ulcer.     {Lewis   Gregory    Cole,     in 
American  Journal  of  Roentgenology,  November,  1915.) 


pert  Roentgenologists  to  realize  what  aid  may  be  given  them,  and 
what  preliminary  preparation  of  the  patient  is  necessary  to  render  the 
skiagraphic  examination  of  value. 

When  possible,  the  patient's  gastro-intestinal  tract  should  be  thor- 
oughly emptied.  This  is  best  accomplished  by  means  of  a  purge  and 
abstinence  from  food.  Liquids  may  be  administered  if  necessary, 
but  even  this,  diet  should  be  limited  to  broths,  albumen  water,  etc. 
Milk  is  apt  to  form  curds,  and  these  may  be  very  misleading.     The 


GENERAL   DIAGNOSTIC    CONSIDERATIONS 


63 


patient  should  be  prepared  to  remove  the  clothing  from  the  abdomen. 
It  is  generally  better  to  remove  all  clothing,  substituting  a  dressing 
gown  without  buttons,  or  a  sheet  which  will  cover  the  entire  body. 

Not  only  is  the  technique  of  making  the  radiographs  of  the  ali- 
mentary tract  difhcult,  but  the  interpretation  of  the  findings  is  also  a 
matter  of  expert  knowledge.  Study  of  Fig.  25,  which  is  a  normal,  and 
of  Fig.  26  a  pathological  stomach,  will  convince  anyone  of  the  ease  witli 
which  an  error  may  be  made. 

More    information    of  value   can   probably   be   obtained    from   a 


Fig.  26. — Slightly  InJurdLcd  Ulcer  with  Slit-liku  Crater.  From  a  Patient  under  the 
Care  ot  the  Senior  Author.  (Lewis  Gregory  Cole,  in  American  Journal  of  Roentgenology^ 
November,  1915.) 


roentgenologic  examination  of  the  stomach,  than  from  that  of  any  other 
viscus  in  the  upper  abdomen.  This  organ  is  studied  after  it  has  been 
rendered  transparent  by  inflating  it  with  air,  or  after  rendering  it 
opaque  by  the  ingestion  of  some  bismuth  or  barium  preparation.  Air, 
as  a  rule,  does  not  distribute  itself  well  in  the  stomach,  and  is  really 
important  only  in  the  study  of  the  fundus  or  "  upper  pole." 

The  stomach  normally,  and  except  when  adherent  to  surrounding 


64  SURGICAL  DISEASES  OF  THE  STOMACH  AND  DUODENUM 

structures,  is  distinctly  movable  and  changes  its  contour  and  position 
with  the  position  of  the  patient's  body.  The  posture  of  the  patient, 
therefore,  should  vary  according  to  the  portion  of  the  stomach  which 
it  is  desired  to  examine.  The  standing  posture  generally  is  the  most 
useful.  In  this  position  the  axis  of  the  stomach  is  almost  vertical  and 
the  organ  is  situated  almost  entirely  to  the  left  of  the  median  line.  The 
lower  one-third  is  more  or  less  horizontal,  but  the  upper  two-thirds 
are  nearly  vertical  in  this  position.  The  upper  pole  normally  rests 
against  the  diaphragm;  the  lower  pole  in  the  standing  position  reaches 
to  the  umbilicus  or  lower  and  is  little  lower  than  the  pylorus.  In  gas- 
troptosis  the  lower  pole  of  the  stomach  may  reach  any  distance  below 
this  level.  In  the  dorsal  decubitus  the  greater  portion  of  the  stomach 
occupies  the  left  hypochondrium.  Most  text-book  illustrations  are 
made  with  the  viscera  in  position  as  seen  on  the  operating  or  dissecting 
table,  and  hence  do  not  give  an  accurate  idea  of  the  position  assumed 
by  the  stomach  when  the  patient  is  erect. 

A  portion  of  barium  mixture  may  be  administered  with  the  patient 
standing.  By  fluoroscopic  examination  a  swallow  of  liquid  food  may 
be  seen  to  enter  the  stomach  completely  in  about  seven  seconds.  A 
delay  usually  means  some  constriction  at  the  cardiac  orifice,  either 
spasmodic  or  organic.  If  this  constriction  is  organic,  solid  portions  of 
food,  or  bismuth  capsules  or  pills,  will  be  retained  a  longer  time,  ac- 
cording to  their  size,  the  calibre  of  the  constriction,  and  the  degree  of 
solubility  of  the  ingested  material.  If  due  to  malignant  change,  the 
constriction  usually  can  be  outlmed  in  the  gaseous  field  which  occupies 
the  upper  portion  of  the  stomach  when  the  patient  is  in  a  standing 
posture. 

A  constriction  of  the  duodenum  at  times  may  be  shown  by  a  dilata- 
tion of  the  portion  preceding  the  stricture.  A  duodenal  ulcer  may  be 
detected  by  signs  analogous  to  those  of  gastric  ulcer,  especially  if  a  niche 
is  visible. 

The  solid  organs  of  the  upper  abdomen  cannot  be  so  easily  examined 
by  means  of  the  X-ray;  but  Dandy  (1919),  Stewart,  and  others 
have  shown  that  in  cases  of  intestinal  perforation,  with  escape  of 
air  into  the  peritoneal  cavity,  the  outlines  of  the  liver  and  diaphragm 
may  be  clearly  seen  in  skiagraphs;  and  that  in  dogs,  the  experimental 
injection  of  500  cc.  of  air  into  the  peritoneum  renders  \isible 
practically  all  the  intra-abdominal  organs,  and  appears  to  do  the 
animals  no  harm.  The  method  has  been  employed  occasionally  also 
in  man. 

Lesions  of  the  stomach  itself  may  also  be  detected  by  fluoroscopy 


GENERAL   DIAGNOSTIC   CONSIDERATIONS  65 

though  some  roentgenologists  maintain  that  a  series  of  X-ray  plates, 
made  in  as  rapid  succession  as  possible  (serial  roentgenography),  is 
preferable. 

Delayed  emptying  of  the  stomach,  evidenced  by  the  presence  of  a 
residue  from  the  opaque  meal  more  than  six  hours  after  its  ingestion, 
is  one  of  the  most  valuable  and  readily  detected  signs  of  disease,  par- 
ticularly of  ulcer  or  carcinoma;  but  it  may  indicate  nothing  more 
than  retention  from  gastroptosis.  Too  rapid  emptying  of  thd  stom- 
ach occurs  in  some  cases  of  duodenal  ulcer,  and  is  associated  with 
hyperperistalsis. 

A  gastric  ulcer  of  comparatively  recent  formation  may  be  detected  by 
observing  that  there  is  a  constantly  locahzed  obstruction  to  the  normal 
peristaltic  waves  (Cole,  1915).  An  ulcer  of  long  standing,  which  has 
become  callous  and  indurated,  presents  (in  addition  to  the  constant 
interference  with  peristalsis  at  a  given  point)  also  a  shadow  cast  by  the 
opaque  material  which  fills  its  crater;  this  shadow  is  known  as  Haudek's 
niche.  If  a  chronic  perforation  (p.  84)  is  present  the  shadow  of  the 
accessory  pocket  may  also  be  visible  in  the  skiagraph.  When  the 
gastric  ulcer  is  at  or  near  the  lesser  curvature,  as  is  usually  the  case,  there 
is  nearly  always  a  constriction  in  the  neighboring  gastric  wall  which 
shows  itself  as  an  "incisura"  at  the  greater  curvature.  According  to 
Carman,  a  true  incisura  should  be  subjected  to  and  withstand  the  fol- 
lowing tests:  (i)  It  must  be  constant  and  stationary;  (2)  it  must  be 
present  when  the  stomach  hangs  normally;  (3)  it  must  survive  vigorous 
palpation;  and  (4)  it  must  persist  after  the  patient  has  been  given  an 
antispasmodic  to  physiologic  effect  (as,  for  example,  tincture  of  bella- 
donna, 10  drops,  three  times  daily  for  two  or  three  days  or  until  flush- 
ing of  the  skin  and  disturbance  of  vision  results) .  A  deep  incisura  may 
be  mistaken  for  the  contraction  of  a  true  liour-glass  stomach. 

A  carcinomatous  ulcer  can  with  difficulty  be  distinguished  from  a 
benign  callous  ulcer, ^  but  a  well  developed  carcinoma  presents  fairly 
characteristic  roentgenologic  signs,  especially  a  filling  defect  at  one 
portion  of  the  outline,  due  to  the  projection  of  the  tumor  into  the  cavity 
of  the  stomach. 

1  Other  competent  roentgenologists  do  not  agree  with  Cole,  who  categorically  asserts: 
We  can  state  that  a  patient  has  not  a  cancer  of  the  stomach  with  as  great  a  degree  of 
certainty  as  we  can  state  that  he  has  not  a  fracture  of  the  hip."  (N.  Y.  Med.  Jour., 
1915,  ii,  26.) 


CHAPTER  IV 
GASTRIC  ULCER 

Pathogenesis. — Ulceration  of  the  stomach  may  occur  as  the  result 
of  tuberculous,  syphiUtic,  or  malignant  disease,  but  the  form  which 
concerns  us  in  this  chapter  has  no  such  specific  cause.  Though  gastric 
ulcers  have  certain  very  marked  characteristics  which  distinguish  them 
from  many  other  ulcers,  there  is  really  httle  that  is  mysterious  about 
them.  They  are  due  to  the  same  causes  as  ulcers  elsewhere  in  the 
body,  and  seem  to  owe  their  peculiarities  only  to  their  situation. 

Their  pathogenesis  has  been  studied  especially  by  Dieulafoy,  by 
Gandy,  by  Hort,  and  lastly  by  Bolton.  From  the  Paris  Thesis  of 
iGandy  (1899),  which  exposes  the  views  of  Dieulafoy,  and  from  the 
recent  excellent  monograph  of  Bolton,  much  of  what  follows  is  derived. 

Gandy  showed  that  in  nearly  all  toxemias  there  are  gastro-intestinal 
ulcers,  and  that  in  almost  all  cases  of  gastro-intestinal  ulceration 
there  is  present  some  form  of  toxemia.  He  pointed  out  the  remark- 
able similarity  which  exists  between  the  ulcers  of  toxemias  (including 
the  intestinal  ulcers  met  with  in  cases  of  burns),  and  the  so-called 
simple  ulcers  of  the  stomach.  They  are  alike  in  latency,  in  tendency 
to  hemorrhage  and  perforation,  and  in  their  acute  formation.  They  are 
also  alike  in  their  clinical  course;  the  earliest  stage  in  all  is  ecchymosisj 
then  hemorrhagic  infarct;  slough;  hemorrhagic  erosion;  "ex-ulcer- 
atio  simplex"  of  mucosa;  true  ulceration  with  hemorrhagic  borders;, 
and  finally  perforating  ulcer,  or  chronic  ulcer  with  thickened  border,, 
or  a  cicatrix.  He  was  able  to  trace  these  forms  in  (ij  burns;  (2)  in- 
fantile diseases  (melena) ;  (3)  infections  (erysipelas,  septicemia,  py- 
emia, local  septic  infections,  variola,  scarlatina,  purpura,  puerperal 
infection,  infections  of  uterus  and  annexa,  infections  of  genito-urin- 
ary  apparatus,  strangulated  hernia,  biliary  infections,  pneumonia, 
pleural  infections,  phthisis,  diphtheria,  articular  rheumatism,  rabies, 
tetanus,  cholera,  dysentery,  typhoid  fever,  etc.).  In  infantile  diseases,, 
burns,  and  typhoid  fever  he  was  able  to  find  pathological  changes  re- 
presenting each  of  the  degrees  above  mentioned,  beginning  with  ecchy- 
mosis,  and  ending  with  perforation.  He  remarks,  further,  that  observers 
have  for  many  years  noted  all  the  above  lesions  in  other  parts  of  the 
stomach  or  digestive  tube,  in  cases  of  gastric  ulcer,  but  do  not  seem 

67 


68  GASTRIC  ULCER 

to  have  appreciatetl  the  fact  that  they  probably  represented  earlier 
stages  of  the  same  process.  In  patients  with  gastric  ulcer  it  is  proba- 
ble that  the  toxemia  is  always  of  infectious  origin;  and  previous  lesions 
of  the  liver  and  kidneys,  by  increasing  the  toxemia,  may  act  as  pre- 
disposing causes. 

Somewhat  similar  views  have  been  expressed  by  Hort.  With  the  ad- 
vantages which  the  most  recent  researches  in  chemical  biology  have 
placed  in  the  physician's  power,  Hort  has  been  able  to  carry  the  theory 
of  the  toxemic  origin  of  gastric  and  duodenal  ulcers  one  step  further. 
He  thinks  gastric  ulcer,  including,  as  above  stated,  ecchymosis,  erosion 
and  actual  ulcer,  is  due  to  a  general  blood  disease,  in  the  nature  of  a 
toxemia,  the  local  effects  in  the  stomach  being  due  to  the  production 
of|hemorrhagins,  which  eat  through  the  endothelial  lining  of  the  blood- 
vessels; and  secondly  to  mucolysins,  which  destroy  the  gastric  mucosa. 

Chnical  experience,  that  best  of  teachers,  has  been  indicating  during 
the  past  few  years  that  in  a  very  large  number  of  cases  of  gastric  ulcer 
the  original  focus  of  infection  lies  in  the  appendix  vermiformis^  and 
the  investigations  of  Rosenow,  as  to  the  elective  localization  of  strepto- 
cocci, are  a  further  confirmation  of  the  view  of  the  infectious  origin  of 
gastric  ulcers  and  similar  lesions.  These  studies  indicate  that  the  cells 
of  the  tissues  for  which  a  given  strain  of  bacteria  shows  elective  affinity 
may  "take  bacteria  out  of  the  circulation  as  if  by  a  magnet — adsorption." 

Bolton  has  shown  by  careful  histological  studies,  that  the  initial 
lesion  in  gastric  ulcer  is  (a)  localized  necrosis  of  the  mucous  membrane; 
(b)  localized  hemorrhage  in  the  mucous  membrane;  or  (c)  inflammation 
of  the  lymphatic  follicles  at  the  bases  of  the  gastric  glands,  upon  the 
muscularis  mucosae.  Necrosis,  he  points  out,  is  due  usually  to  bacteria 
or  their  toxins  circulating  in  the  blood  stream,  and  not  to  the  food 
contents  of  the  stomach;  poisons  of  metabolic  origin,  such  as  the  gastro- 
toxin  described  by  Bolton  himself,  act  in  a  similar  manner.  The  cells 
of  the  gastric  mucosa  being  primarily  injured  by  circulating  poisons, 
necrosis  is  readily  produced  by  the  local  action  of  the  gastric  juice. 
Necrosis  may  arise  in  this  way  without  any  preceding  hemorrhagic 

'Moynihan  (1910)  >was  one  of  the  earliest  to  call  attention  to  the  relation  which  exists 
between  appendicitis  and  gastric  lesions.  One  of  us  (Ashhurst)  has  narrated  elsewhere 
(1914)  several  interesting  cases  in  which  the  relation  was  too  close  to  be  easily  overlooked; 
(i)  occurrence  of  gastric  perforation  just  one  year  after  removal  of  an  acutely  inflamed 
appendix;  (2)  occurrence  of  gastric  symptoms  three  years  after  removal  of  a  gangrenous 
appendix,  and  the  finding  of  a  subacute  perforation  of  the  stomach  at  the  second  operation. 
Indeed,  the  more  often  the  abdomen  is  opened  for  gastric  symptoms,  without  neglecting 
at  the  same  time  to  investigate  the  condition  of  the  appendix,  the  rarer  does  it  become  not  to 
find  gross  evidence  of  disease  in  the  latter  structure. 


PATHOGENESIS  69 

change  or  lymphatic  inflammation.  Preceding  hemorrhage,  however, 
is  actually  a  frecjuent  cause  of  gastric  ulcer,  and  is  due  to  bacterial 
toxins  circulating  in  the  blood  stream  and  destroying  the  endothelial 
cells  of  the  capillaries,  thus  paving  the  way  for  the  local  destructive 
action  of  the  gastric  juice.  Inflammation  of  the  lymphatic  follicles 
in  the  stomach  has  been  recognized  since  the  ^  time  of  Cruveilhier 
(1835-42).  Though  sohtary  follicles  occur  all  over  the  stomach, 
between  the  mucosa  and  the  muscularis  mucosa?,  they  are  most  thickly 
studded  along  the  lesser  curvature,  and  especially  toward  the  pylorus. 
The  formation  in  one  or  more,  perhaps  in  very  many,  of  these  follicles, 
of  a  submucous  abscess,  followed  by  its  rupture  into  the  gastric  cavity, 
allows  the  gastric  juice  to  act  on  the  base  of  the  ulceration  thus  exposed. 

An  ulceration  formed  in  one  of  the  ways  above  indicated  would  soon 
heal  in  other  situations,  or  in  a  normal  stomach;  but  when  constantly 
exposed  to  the  action  of  the  gastric  juice  (especially  if  hyperacid)  it 
shows  no  tendency  to  heal,  but  rather  to  extend.  It  extends  faster 
(sometimes  exceedingly  fast)  if  there  is  pyloric  obstruction,  or  if  there 
is  any  systemic  or  localized  infection.  In  such  cases  sudden  hemor- 
rhage or  perforation  may  be  the  first  indication  of  gastric  disease. 

A  few  words  should  be  said  in  tliis  place  in  regard  to  what  may 
perhaps  be  called  the  mechanical  theory  of  the  pathogenesis  of  gastric 
and  duodenal  ulcers.  It  is  mentioned  also  in  Chapter  XVI  in  connec- 
tion with  the  stagnant  gall-bladder. 

This  theory  has  been  ably  presented  in  a  recent  paper  of  great 
interest  by  Waugh  (1920).  He  points  out  that  Lane's  theories  of 
toxic  absorption  as  a  result  of  intestinal  stasis  being  the  cause  of  varied 
lesions  have  not  met  with  general  acceptance.  And  Waugh  suggests 
that  a  congenitally  mobile  cecum  and  ascending  colon  may  by  their 
drag  exert  injurious  traction  upon  certain  of  the  upper  abdominal  or- 
gans (stomach,  pylorus,  gall-bladder)  if  these  are  well  fixed;  whereas  if 
they  are  not  well  fixed,  gastroptosis,  etc.,  will  result.  Now  he  proposes 
the  theory  that  such  points  of  injurious  traction  in  the  pyloric  region 
of  the  stomach  or  the  duodenum  form  places  of  lessened  resistance 
in  which  the  ulcers  are  prone  to  develop.  This  theory  thus  obviates 
the  necessity  for  assuming  a  toxemia  from  chronic  intestinal  stasis, 
which  has  never  been  proved  to  exist.  Waugh  points  out,  moreover, 
that  in  these  cases  {cceciim  mobile)  surgical  treatment  should  be  pre- 
ventive, as  the  ulcers  and  other  lesions  seen  in  adult  life  are  end  results 
and  cannot  be  cured  by  removal  of  the  cause.  True  preventive 
measures,  he  contends,  consist  in  proper  fixation  of  the  cecum  and 
ascend-colon  in  childhood. 


70  GASTRIC  ULCER 

Pathology. — There  is  very  little  doubt  that  every  so-called  chronic 
or  callous  or  indurated  ulcer  was  at  one  time  acute,  and  began  in  one  of 
the  ways  above  described.  By  gross  inspection  we  may  recognize  the 
two  following  main  classes  of  lesions:  (a)  Erosions;  and  {b)  Ulcer  or 
Ulcus. 

(o)  Erosions  ("Follicular  erosions"  of  Cruveilhier;  "punctate 
erosions"  of  Brinton) . — Under  this  heading  may  be  recognized  recently 
formed  (aaite)  lesions  of  the  gastric  mucosa,  so  small  as  often  to  be 
found  only  after  considerable  search,  and  appearing  as  mere  abrasions 
of  the  mucous  membrane.  They  extend  no  deeper  than  the  umscu- 
laris  mucosae,  seldom  or  never  cause  symptoms,  and  probably  in  the 
vast  majority  of  cases  heal  promptly  without  leaving  any  scars.  The 
"exulceratio  simplex"  described  by  Dieulafoy  may  be  regarded  as  a 
slightly  more  advanced  form;  it  includes  the  muscularis  mucosas. 
Ulcerations  as  distinguished  from  erosions,  may  involve  the  entire  thick- 
ness of  the  gastric  wall  sometimes  give  rise  to  alarming  hemorrhages, 
and  may  perforate.  They  may  coincide  with  the  erosions,  and  are 
probably  due  to  the  same  cause.  They  are  not  palpable  from  the 
serous  surface  of  the  stomach,  but  heal  with  the  formation  of  slight 
cicatrices,  which  often  may  be  recognized  at  operation  or  autopsy. 
These  scars  are  more  frequent  in  the  cardiac  half  of  the  stomach 
showing  that  here  they  heal  more  readily,  while  near  the  pylorus  the 
unhealed  ulcerations  are  more  frequently  found. 

{b)  Ulcer  or  Ulcus  ("Simple,  "round,"  or  "peptic"  ulcer). — 
If  the  ulcerations  just  described  do  not  heal  soon,  they  become  indis- 
tinguishable from  "ulcus"  which  is  the  form  commonly  intended  when 
"gastric  ulcer"  is  mentioned.  The  recent  formation  of  such  an  ulcer  is 
frequently  indicated  by  the  presence  of  a  partly  adherent  black  slough 
(Plate  I,  a),  the  black  color  being  due  to  the  action  of  the  gastric 
hydrochloric  acid  on  the  hemoglobin  in  the  ulcer.  The  most  recent 
ulcers  of  this  type  are  the  classical  round,  open  "punched  out"  gastric 
ulcers.  If  healing  is  delayed,  the  edges  of  the  ulcer  become  sloping, 
the  ulcer  grows  more  or  less  conical  in  shape,  its  borders  are  thickened, 
and  the  surrounding  mucosa  becomespuckered  up  (Plate  I,  b) .  Bolton's 
studies  further  show  that  as  long  as  the  ulcer  is  extending  in  area  its 
edges  areundermined  andoverhanging,  that  the  submucosais  thickened, 
and  that  the  sloughs,  formed  at  the  expense  of  the  submucous  coat, 
show  evidence  of  digestion  at  their  edges  by  the  gastric  juice. 
The  final  stage,  in  which  healing  is  probably  impossible,  is  that  of 
chronic,  callous,  indurated  ulcer,  with  thick,  hard,  raised,  undermined 
borders,  and  with  its  base  covered  with  tenacious  mucus. 


Plate  I 


(a)  Chronic  Gastric  Ulcer  on  Lesser  Curvature;  Specimen  Secured  by  Excision.  Note 
the  Thickened.  Edematous  Gastric  Wall,  the  Enlarged  Lymphnodes  in  the  Attached 
Omentum,  and  the  Recent  Clot  Covering  the  Ulcer's  Base.  Female,  39  Years,  in  Good 
Health  2  Years  Later.      Path.  No.  8888.     Lankenau  Hospital. 


(b)  Callous  Gastric  Ulcer  on  Posterior  Wall  near  Lesser  Curvature;  Specimen  Secured 
by  Excision.  Note  the  Radiating  Cicatricial  Bands,  the  Sclerosed  Margins  of  the  Ulcer, 
Its  Base  Covered  with  Adherent  Slough,  and  the  Thickened  Edematous  Gastric  Wall. 
Male,  63  Years,  in  Good  Health  2  Years  Later.      Path.  No.  8774.     Lankenau  Hospital. 

Face  p.  70 


CLINICAL   PATHOLOGY  "  7 1 

Among  143  specimens  of  ulcer  (48  gastric  and  95  duodenal)  excised 
by  the  senior  author  and  studied  microscopically  by  Reiman  (1920), 
22  were  classed  as  acute  (s  gastric  and  17  duodenal),  91  as  chronic 
(29  gastric  and  62  duodenal);  while  30  ulcers  (14  gastric  and  16 
duodenal)  were  chronic  but  gave  evidence  of  recent  acute 
exacerbations. 

Clinical  Pathology. — Although  erosions  and  ulcerations  almost 
invariably  are  multiple,  the  true  gastric  idcer  is  single  in  about  77 
per  cent,  of  cases,  and  the  chronic  callous  ulcer  is  single  in  from  80 
to  90  per  cent,  of  cases  (Bolton) .  In  more  than  half  the  cases  there  are 
multiple  small  white  scars,  left  by  healed  ulcerations.  The  site  of 
the  ulcer  usually  is  near  the  lesser  curvature,  and  much  more  often  in 


Pig.  27. — ^Diagram  Indicating  in  Percentage,  the  Sites  of  268  Ulcers  (53  Gastric  and 
215  Duodenal) ,  Recently  Encountered  at  Operation  by  the  Senior  Author.  In  3  per  cent,  of 
the  Cases  of  Duodenal  Ulcer,  Two  Ulcers  Were  Found,  One  in  the  First,  the  Other  in  the 
Second  Part  of  the  Duodenum.     {Lankenaii  Hospital.) 

the  pyloric  region  of  the  stomach  than  elsewhere.  Probably  this  is 
owing  to  the  large  number  of  lymph  foUicles  along  the  lesser  curvature, 
and  because  ulcerations  in  other  parts  of  the  stomach  show  little  ten- 
dency to  remain  unhealed.  Scars  of  healed  ulcerations  are  much  more 
often  encountered  in  the  body  and  cardiac  portions  of  the  stomach 
than  in  the  pyloric  region  or  along  the  lesser  curvature.  Unhealed 
ulcers  are  also  more  frequent  on  the  posterior  than  on  the  anterior  wall 
of  the  stomach.  The  existence  of  similar  ulcers  on  the  anterior  and 
posterior  walls  near  the  lesser  curvature  (the  so-called  "kissing  ulcer") 
is  more  probably  due  to  similar  relations  to  the  blood  supply  than  to 
any  fancied  infection  of  another  portion  of  the  stomach  by  an  existing 
ulcer.  Figure  27  indicates  the  sites  of  268  ulcers  (53  gastric  and  215 
duodenal)  recently  encountered  at  operation  by   the  senior  author. 


72  GASTRIC  ULCER 

The  course  pursued  by  gastric  ulcers  does  not  differ  materially 
from  that  of  ulcers  of  any  other  region  exposed  to  such  constant  injury. 
If  the  early  symptoms  are  sufficiently  severe  to  compel  attention  and 
procure  for  the  patient  appropriate  medical  treatment,  the  ulcers  usu- 
ally will  heal,  it  is  believed,  leaving  only  insignificant  cicatrices.     If, 

however,  the  symptoms  at  the  onset  are 
not    very    severe,    proper     treatment    is 


""""""  neglected,  and  the  lesions,  especially  those 
along  the  lesser  curvature  and  near  the 
pylorus,  develop  into  true  round  "open" 
ulcers.  Ulcers  of  the  stomach  have  been 
compared  to  leg  ulcers  and  the  resem- 
blance is  in  many  respects  close.  Both 
develop  insidiously,  and  are  endured  by 
V   -'  '  the    patient    because    not    very    acute    in 

Pig.  28.— Ulcer  un  the  Lesser  Curv-  character,   and   because  proper   treatment 

ature;  a  Very  Frequent  Site.  ,,  ..,  •.  .•  r^u 

would  necessitate  interruption  oJ  the 
usual  activities  of  life.  The  longer  gastric  ulcers  remain  unhealed, 
the  longer  time  will  be  required  for  their  repair  by  medical  means; 
indeed,  it  is  doubtful  whether  a  true  gastric  ulcer,  as  distinguished 
from    an    erosion,    is  ever  healed   under    purely  medical  treatment. 


7/' 


.y 


Fig.  29. — Twin   Ulcers  Each  Side  of  the  Cardiac  Orifice.     A  Very  Unusual  Site.     From  a 
Patient  in  the  Lankenau  Hospital. 

Though  latency  may  be  procured  by  these  means,  recurrence  after 
medical  "cure"  is  frequent;  and  it  must  be  frankly  confessed  that 
even  surgical  operations  are  not  sure  preventatives  of  recurrence, 
since  they  at  most  place  the  patient  in  the  same  condition  with  respect 


CLINICAL   PATHOLOGY  73 

to  future  gastric  ulcers  as  he  was  before  the  development  of  the  ulcer 
for  which  the  operation  was  done. 

When  a  simple  ulcer  has  once  formed  in  the  stomach  it  shows  no 
innate  tendency  to  heal.  Its  tendency,  on  the  contrary,  is  to  remain 
unhealed,  and  eventually  to  become  callous.  At  any  time  after  its 
first  appearance  as  an  erosion  it  may  give  rise  to  the  acute  complica- 
tions, hemorrhage  or  perforation.  As  far  as  duration  alone  is  con- 
cerned, it  soon  becomes  a  "chronic"  ulcer  whatever  its  special  char- 
acteristics may  be.  But  it  is  not  always  possible  merely  by  looking  at 
an  ulcer  to  determine  its  duration;  and  when  several  ulcers  co-exist, 
it  is  often  manifest  that  some  of  them  are  much  more  recent  than 
others.  Nor  does  the  duration  of  the  clinical  symptoms  always  decide 
upon  the  age  of  the  ulcer.  It  is  frequently  impossible  to  tell  which 
one  of  several  ulcers  has  caused  symptoms  the  longest.  An  ulcer 
may  have  been  latent  for  a  considerable  period  before  producing  symp- 
toms, or  may  have  become  quiescent  some  time  since,  and  the  recent 
symptoms  may  have  been  caused  by  a  more  recently  developed  ulcer, 
or  by  one  which,  though  present  for  a  long  time,  only  recently  has 
become  symptom  producing.  As  a  rule,  however,  it  is  safe  to  assume 
that  an  ulcer  with  callous  edges,  and  with  its  margin  shelving  rather 
than  punched  out,  is  an  ulcer  of  long  duration — possibly  ten  to  fifteen 
years;  while  an  ulcer  resembling  in  character  the  "exulceratio  simplex" 
of  Dieulafoy  is  manifestly  of  quite  recent  formation.  The  "acute 
round  ulcer,"  simple  or  peptic  ulcer,  which  appears  cut  out  of  the 
stomach  wall,  is  of  indefinite  duration,  and  while  we  can  say  that 
it  has  not  existed  as  long  as  an  ulcer  with  callous  margins,  we  cannot 
be  certain  that  it  has  existed  longer  than  a  few  months  or  even  weeks. 

This  simple  "punched  out"  ulcer  is  still  actively  ulcerating,  and 
has  not  commenced  to  granulate  to  any  appreciable  degree.  Its 
base  is  formed  by  the  muscularis  of  the  gastric  wall,  and  it  is  much 
more  prone  to  perforation  than  is  an  ulcer  of  the  callous  type.  And 
when  perforation  takes  place  in  this  punched  out  ulcer,  the  peritoneal 
cavity  is  usually  at  once  involved,  and  the  stomach  contents  escape 
into  the  general  abdominal  cavity  unchecked  by  adhesions.  A  cal- 
lous ulcer,  on  the  other  hand,  has  its  base  covered  with  granulations. 
Its  base,  but  more  especially  its  margin,  shows  the  result  of  long- 
standing reactive  inflammation,  and  the  stomach  walls  are  correspond- 
ingly thickened.  Hence  perforation  in  this  type  of  ulcer  is  much 
more  unusual  than  in  the  acute  round  ulcer,  and  when  perforation 
does  occur,  the  base  of  the  ulcer  is  frequently  adherent  to  some  neigh- 
boring organ,  particularly  the  pancreas  or  the  liver,  or  is  so  protected 


74 


GASTRIC  ULCER 


by  adhesions  to  the  intestinal  tract  or  the  omentum,  that  general 
infection  of  the  peritoneum  rarely  occurs  at  once.     The  formation  of  a 


Fig.  30. — Above  is  Seen  a  Specimen  Removed  by  Partial  Gastrectomy:  Callous  Ulcer 
of, .the  Anterior  Wall  of  the  Stomach.  Division  of  Adhesions  to  the  Mesocolon  Damaged 
the^Circulation  of  the  Transverse  Colon,  a  Section  of  Which  Was  Simultaneously  Resected, 
and^is  Represented  in  the  Lower  Drawing.  Patient  Free  from  Symptoms  One  Year  Later. 
See|Also  Fig.  31.  From  a  Patient  under  the  Junior  Author's  Care  in  the  Episcopal 
Hospital. 

subphrenic  or  subhepatic  abscess,  or  an  empyema  of  the  lesser  peri- 
toneal cavity,  very  frequently  in  these  cases  precedes  generalized 


SYMPTOMS  75 

peritoneal  infection,  and  renders  possible  the  application  of  surgical 
measures  in  time  to  prevent  the  latter  complication. 

The  erosion  seem  more  apt  than  other  forms  of  ulceration  to  give 
rise  to  sudden  and  overwhelming  hemorrhage,  appearing  as  the  first 
symptom  of  gastric  lesion,  and  at  times  leading  to  sudden  death.  The 
bleeding  is  in  the  nature  of  a  general  venous  ooze.  Usually  a  history 
of  some  recent  acute  constitutional  infection  (grippe,  tonsillitis,  bron- 
itis,  etc.)  is  obtainable  in  these  cases.  The  punched  out  ulcer  gives 
rise  to  acute  and  recurring  hemorrhages  by  ulcerating  into  a  blood 
vessel.  The  bleeding  is  as  a  rule  safely  checked  by  non-operative 
means,  but  operation  is  indicated  to  prevent  a  recurrence  of  this  alarm- 
ing feature.  The  callous  ulcer  is  the  variety  which  produces,  more  fre- 
quently than  any  other,  those  occult  hemorrhages  which  induce  the 
severe  anemia  not  infrequently  encountered  in  this  disease. 

In  form,  the  punched  out  ulcer  is  generally  well  described  by  its 
usual  name  of  "round  ulcer,"  while  the  callous  ulcer  is  more  or  less 
irregular  in  outline,  sometimes  appearing  as  if  formed  by  the  coales- 
cence of  several  smaller  ulcers,  and  usually  having  its  long  axis  trans- 
verse to  the  long  axis  of  the  stomach.  It  is  this  form  of  ulcer  which  is 
chiefly  productive  of  gastric  distortions,  such  as  pyloric  stenosis  and 
hourglass  stomach. 

Symptoms 

Gastric  ulcer  is  a  chronic  disease,  with  acute  or  subacute  exacer- 
bations; and  as  it  is  usually  during  one  of  these  exacerbations  that  the 
patient  seeks  medical  advice,  the  attention  of  physicians  was  for  years 
focussed  on  the  symptoms  present  at  these  times,  namely  pain,  vomiting, 
tenderness.  It  is  convenient,  therefore,  first  to  describe  in  some  detail 
these  definite  symptoms  and  the  two  main  complications  of  gastric 
ulcer  (hemorrhage  and  perforation),  and  finally  under  the  head  of 
diagnosis  (p.  92)  to  attempt  a  summary  of  what  is  at  present  known  of 
the  features  of  this  many-sided  disease. 

Erosions  and  ulcerations  seldom  give  rise  to  symptoms  other  thati 
hemorrhage  or  perforation.  They  form  the  most  acute  class  of  gastric 
ulcers  not  only  in  the  sense  of  their  symptomatology,  but  also  in  their 
duration,  since  most  of  them  heal  very  rapidly  without  having  at  any 
time  been  productive  of  symptoms  of  any  kind. 

The  typical  gastric  ulcer  is  that  form  of  the  affection  which  of  all 
others  is  characterized  by  pain.  It  should  not  be  taken  for  granted, 
however,  that  no  ulcer  exists  when  pain  is  absent.  As  previously 
noted,  an  open  ulcer  may  remain  latent  until  its  presence  is  announced 


76  GASTRIC  ULCER 

by  hemorrhage  or  perforation.  But  the  pain  when  it  does  occur  is 
sufficiently  characteristic  to  make  it  necessary  for  the  physician  to  give 
it  his  careful  attention.  When  the  stomach  is  empty  there  is  rarely  any 
pain,  but  very  soon,  sometimes  immediately  after  food  is  swallowed, 
a  soreness  or  a  sharp  stabbing  pain  will  arise  at  some  well-defined  spot 
in  the  epigastrium;  and  this  soreness  will  persist,  and  probably  grow 
continually  worse,  until  the  stomach  is  emptied,  either  by  vomiting  or 
by  the  discharge  of  its  contents  into  the  duodenum. 


Fig.  31. — The  Stomach  Shown  in  Fig.  30  Has  Been  Cut  Along  the  Lesser  Curvature,  and 
the  Anterior  Wall  Has  Been  Turned  Down  Along  the  Greater  Curvature  as  a  Hinge,  Ex- 
posing the  Deep  Crater  of  the  Callous  Ulcer  Forming  the  Palpable  Tumor  in  the  Anterior 
Wall.      (Episcopal  Hospital.) 

It  is  not  possible  to  decide,  from  the  site  of  the  pain  or  from  the  inter- 
val after  ingestion  of  food  at  which  it  first  appears,  in  precisely  what 
region  of  the  stomach  the  ulcer  is  situated,  nor  to  determine  the  nature 
of  that  ulcer,  though  it  may  be  taken  as  a  general  rule  that  the  longer  the 
interval  between  ingestion  of  food  and  occurrence  of  pain  the  nearer  the 
ulcer  is  to  the  outlet  of  the  stomach. 

The  cause  of  the  pain  is  still  a  matter  of  dispute.  Although  the 
nerve  supply  of  the  stomach  is  largely  derived  from  the  pneumogastric 


SYMPTOMS 


77 


nerve  which  carries  both  sensory  and  motor  fibres,  most  observers 
agree  that  the  stomach  is  devoid  of  common  sensation  such  as  that  with 
which  the  skin  is  endowed.  Lennander  (igoi)  demonstrated  that 
pain  occurs  on  irritation  of  the  parietal  peritoneum,  but  that  the  vis- 
cera are  insensitive  unless  their  mesenteries  are  pulled  upon;  and  tlris 
observation  is  frequently  confirmed  by  surgeons  who  operate  under  local 
anesthesia.  Hertz,  in  his  Goulstonian  Lectures  (191 1),  explained 
visceral  pain  by  tension  on  the  walls  of  the  viscera;  thus  in  ulcer  of  the 
stomach  peristalsis  causes  pain  because  the  ulcer  interrupts  the  normal 
peristaltic  current,  as  can  be  seen  on  the  fluoroscopic  screen.  Simi- 
larly, pyloric  obstruction  causes  pain  because  the  stomach  is  stimulated 


Fig.  32. — Microphotograph   of   a    Chronic  Gastric  Ulcer,  Showing  the  Overhanging  Edge. 
(Dr.  Reiman,  Lankenau  Hospital.) 

to  hyperperistalsis.  Thus  it  is  no  longer  believed  that  the  acid  gastric 
juice  causes  pain  by  mere  contact  with  the  gastric  ulcer,  but  only 
because  by  coming  into  contact  with  the  ulcer  it  stimulates  irregular 
peristalsis.  Where  adhesions  to  the  parietal  peritoneum  are  present 
dragging  upon  them  is  another  factor  in  the  production  of  pain. 

Accompanying  the  pain,  and  usually  also  present  in  the  intervals 
between  food,  when  pain  is  often  absent,  will  be  found  a  more  or  less 
well-defined  and  constantly  located  area  of  tenderness  to  pressure. 
This  is  usually  in  the  costal  angle,  a  little  to  the  right  of  the  middle, 
and  varies  from  one  to  six  or  seven  centimeters  in  diameter.  The  fact 
that  this  area  of  tenderness  does  not  vary  with  the  position  of  the  stom- 
ach is  now  generally  acknowledged ;  hence  its  location  is  no  indication 
of  the  site  of  the  ulcer. 


78 


GASTRIC  ULCER 


The  pain  is  not  infrequently  referred  to  some  other  region  as  well  as 
to  the  epigastrium,  particularly  to  the  left  hypochondrium  and  neigh- 
borhood of  the  left  scapula.  But  more  frequently  it  is  the  tenderness 
that  is  referred,  particularly  to  the  dorsal  region.  Peculiarly  charac- 
teristic in  advanced  cases  is  a  tender  spot  to  the  left,  more  rarely  to  the 
right,  of  the  last  two  thoracic  vertebrae.  Pain  and  tenderness  which 
are  referred  are  much  less  usual  in  these  open  ulcers  than  in  those 
which  have  formed  adhesions  in  the  course  of  their  cicatrization  and 
contraction. 


Fig.   33. — Microphotograph.    Showing   Edema  ot    the   Muscularis  Occurring   During  an 
Acute  Exacerbation  of  a  Chronic  Gastric  Ulcer.      (Dr.  Reitnan,  Lankenau  Hospital.) 


Vomiting,  next  to  pain,  is  the  most  constant  symptom  of  gastric 
ulcer.  In  open  ulcers  vomiting  is  often  induced  by  the  pain  which  the 
ingested  food  causes,  and  some  patients  will  voluntarily  produce 
emesis,  by  gagging  themselves,  merely  to  be  relieved  of  their  gastric 
distress.  The  act  of  vomiting  rriay  occur  spontaneously  soon  after 
a  meal  is  taken,  but  when  it  is  a  constant  feature  of  the  disease,  it 
does  not  usually  occur  until  at  least  half  an  hour  or  an  hour  after 
eating.  The  vomited  matter  is  notably  acid  and  malodorous,  and  is 
often  streaked  with  blood.  The  vomiting  usually  is  not  repeated 
until  after  the  next  meal.  IMany  patients  will  have  nausea  but  no 
vomiting. 

Eructations  and  heartburn  are  very  frequent  symptoms  of  gastric 


SYMPTOMS  79 

ulcer,  but  their  significance  usually  is  overlooked,  and  it  is  not  until 
they  are  succeeded  by  actual  vomiting  and  distressing  pain  that  an 
anatomical  cause  is  sought  for. 

Hcmatemesis  may  occur  at  any  time  that  the  ulcer  invades  a  blood 
vessel,  independently  of  the  post-prandial  vomiting.  Profuse  and  pros- 
trating hemorrhage  may  occur  as  the  first  symptom  of  gastric  disease, 
and  is  then  often  due  to  erosions,  being  a  venous  flow  whose  precise 
origin  rarely  is  discoverable  either  at  operation  or  autopsy.  The  possi- 
bility of  there  being  varicosities  in  the  stomach  or  esophagus  should 
not  be  overlooked.  When  the  hemorrhage  is  more  moderate  in 
amount,  but  repeated  at  intervals  of  days,  weeks  or  months,  it  is 
especially  significant  of  the  acute  round  ulcer.  Any  sudden  increase 
in  arterial  tension  may  give  rise  to  such  a  hemorrhage.  The  process 
of  digestion,  with  the  accompanying  increased  activity  and  hyperemia 
of  the  stomach,  is  naturally  the  most  frequent  cause;  but  sudden 
excitement,  straining  at  stool,  and  vomiting,  act  in  the  same  way. 
Hematemesis  is  rare  at  night  when  the  stomach  as  well  as  the  whole 
body  is  at  rest.  Vomiting  of  arterial  blood  is  present,  according  to 
most  observers,  in  from  30  to  50  per  cent,  of  all  cases  of  gastric  ulcer; 
and  minute  traces  of  blood  usually  can  be  found  in  the  vomitus  in 
about  four-fifths  of  the  cases.  Although  it  is  the  round  open  ulcer 
that  is  particularly  characterized  by  vomiting  of  arterial  blood,  yet 
this  symptom  may  be  present  in  the  callous  ulcer.  In  the  latter 
form,  however,  the  blood  is  usually  much  less  in  quantity,  and  is  more 
frequently  clotted  before  it  is  vomited.  Hemorrhage,  as  well  as 
vomiting  are  later  signs  of  gastric  ulcer  than  is  pain. 

Hemorrhage  into  the  stomach  in  cases  of  gastric  ulcer  does  not 
always  produce  immediate  vomiting.  The  blood  may  lie  in  the 
stomach  and  before  vomiting  occurs  may  become  clotted  or  intimately 
mixed  with  food  which  has  been  ingested  subsequent  to  the  occur- 
rence of  the  bleeding.  Or  the  blood  may  be  passed  into  the  intestines 
and  be  finally  evacuated  in  the  stools,  in  which  case  it  is  much  more 
likely  to  be  overlooked. 

A  consideration  of  hemorrhage  leads  naturally  to  a  discussion  of 
the  anemia  which  has  for  so  long  been  regarded  as  a  characteristic 
feature  of  the  open  gastric  ulcer.  It  is  still  an  undecided  question 
whether  the  typical  anemia  is  a  cause  or  a  result  of  the  disease;  but 
it  is  at  any  rate  certain  that  it  is  a  fairly,  constant  feature,  and  opinion 
at  present  is  inclined  to  consider  both  the  anemia  and  the  gastric 
ulcer  as  produced  by  the  same  cause — toxemia.  Particularly  in 
young  females  is  this  anemia  noticed.     A  growing  girl  or  a  young 


8o  GASTRIC  ULCER 

woman  who  is  anemic  and  has  indigestion  should  be  very  carefully 
examined  for  evidence  of  gastric  ulcer.  The  anemia  is  usually  of  the 
chlorotic  type — that  is  to  say,  there  is  a  decrease  in  the  number  of  the 
red  blood  cells,  and  a  still  greater  decrease  in  the  amount  of  hemo- 
globin present;  the  cellular  elements  being  more  quickly  replaced 
after  hemorrhage  than  is  the  hemoglobin.  Inanition  due  to  the 
vomiting  and  to  the  impaired  digestive  powers  of  the  individual,  as 
well  as  the  recurring  hemorrhage  from  the  ulcer  itself,  are  important 
factors  in  maintaining  an  anemia  which  has  once  developed. 

Callous  Ulcer. — This  form  of  ulcer  is  characterized  less  by  acute 
pain  and  hematemesis  than  by  persistent  indigestion,  melena,  which 
is  often  overlooked,  and  symptoms  of  obstruction  of  the  pylorus. 
The  vomitus  may  occasionally  be  streaked  with  blood,  but  the  hemor- 
rhage is  rarely  large  in  amount,  except  when  fatal  from  perforation 
of  some  large  vessel.  The  pain  is  not  so  marked  as  in  open  ulcer, 
the  area  of  tenderness  is  not  so  well  defined,  and  vomiting  does  not 
occur  so  soon  after  the  ingestion  of  food.  The  pain  is  much  more 
apt  to  be  referred  to  some  other  region  of  the  body,  particularly  to 
the  left  scapular  region,  and  is  largely  due  to  pulling  upon  adhesions. 
Perforation  is  rare,  and  when  it  occurs  is  in  the  immense  majority  of 
cases  either  subacute  or  chronic  in  type,  much  more  frequently  pro- 
ducing perigastric  or  subphrenic  abscess  than  immediate  generalized 
peritonitis.  A  palpable  mass  is  not  unusual  in  a  patient  with  a  callous 
ulcer,  and  sometimes  may  closely  simulate  malignant  disease  (Figs. 
30  and  31).  The  most  characteristic  features,  however,  are  those  of 
dilatation  of  the  stomach,  with  food  stasis,  and  regurgitant  vomiting — 
subjects  which  will  be  considered  in  detail  in  a  subsequent  chapter. 

Hemorrh.'\ge  in  Ulcer  of  the  Stom.ach 

As  a  general  statement  it  may  be  said  that  any  of  the  pathological 
varieties  of  ulcer  may  be  the  origin  of  any  form  of  hemorrhage — of  a 
sudden  and  fatal  How  of  blood,  which  kills  in  a  few  minutes;  of  repeated 
hemorrhages  alarming  in  quantity  but  not  immediately  fatal;  or  of 
occult  hemorrhages  only  to  be  detected  at  times  by  persistent  and 
painstaking  microscopical  examination  of  the  vomitus  and  the  feces. 
But  as  a  rule  those  hemorrhages  which  occur  as  the  first  symptom  of 
ulcer,  and  which  quickly  kill  the  patient  by  their  mere  quantity,  are 
found  to  have  their  origin  in  erosions  of  the  mucous  membrane,  and 
not  from  any  well  defined  ulcer.  This  is  the  rule,  and  if  we  could 
know  that  such  a  form  of  ulceration  existed,  we  should  expect  any 


GASTRIC   HEMORRHAGE  8 1 

hemorrhage  which  ruight  occur  to  be  profuse  and  overwhelming  in 
quantity  and  to  be  quickly  fatal. 

Fortunately  innumerable  individuals,  during  some  acute  general 
infection,  may  develop  erosions  which  will  heal  without  causing  any 
symptoms  whatever,  certainly  without  any  hemorrhages.  The  follow- 
ing case  is  cited  as  an  example  of  such  hemorrhages,  eventually  proving 
fatal. 

Repeated  Hematemesis;  Direct  Blood  Transfusion;  Temporary  Improve 
ment;  Operation;  Recurrent  HcmorrJiages,  and  Death 

F.  H.,  male,  aged  twenty-seven  years,  admitted  to  the  Episcopal  Hospital  Sept.  i, 
1914.  Eight  years  previously  he  had  had  an  attack  of  severe  abdominal  pain  with  vomiting, 
which  confined  him  to  bed  for  almost  a  week.  Since  this  attack  he  had  enjoyed  excellent, 
health,  with  never  a  symptom  of  indigestion,  until  the  last  week,  during  which  period  he 
had  suffered  from  distention  after  meals.  The  day  before  admission  he  vomited  1000  cc. 
of  bright  red  blood,  and  on  the  morning  of  admission  he  vomited  500  cc.  of  blood.  The 
feces  had  been  perfectly  black  for  the  past  few  days. 

On  admission  the  patient  was  anemic,  pale  and  exceedingly  restless,  with  a  profuse 
clammy  sweat  over  the  entire  body.  Respirations  were  rapid  and  shallow;  pulse  127,  of 
low  tension  and  volume.  Aside  from  exaggerated  peristalsis  the  abdomen  was  entirely 
negative.     R.B.C.,  2,840,000;  Hb.  42%;  color  index  0.75. 

Two  days  after  admission  the  patient  vomited  1000  cc.  or  niore  of  bright  red  blood, 
together  with  a  few  dark  clots.  Morphin  had  been  given  in  sufficient  quantities  to  check 
peristalsis.  The  patient  complained  of  intense  thirst.  His  extremities  were  cold,  and  the 
body  temperature  was  subnormal.  The  pulse  was  soft,  small,  rapid,  and  at  times  could 
not  be  detected.  R.B.C.,  1,820,000,  Hb.  30  per  cent.,  color  index  0.83.  Direct  transfusion 
was  now  done  (Drs.  J.  W.  Moore  and  J.  P.  Jones).  Within  a  short  time  color  returned  to 
the  blanched  lips  and  the  luster  to  the  eyes.  At  the  end  of  the  transfusion  which  consumed 
12  minutes,  the  pulse  was  full  and  bounding,  the  R.B.C.,  3,110,000;  the  Hb.,  60  per  cent, 
and  the  color  index  0.96. 

Improvement  was  now  rapid,  and  as  no  more  hemorrhages  had  occurred,  on  Sept.  11, 
nine  days  later,  the  hemoglobin  being  62  per  cent..  Dr.  Ashhurst  did  a  posterior  no-loop 
gastro-jejunostomy,  at  the  same  time  inverting  a  small  area  on  the  anterior  gastric  wall, 
4  cm.  from  the  lesser  curvature,  and  midway  between  pylorus  and  cardia.  This  area  was 
covered  by  a  patch  of  recent  lymph,  and  was  thought  to  be  over  an  open  ulcer,  especially 
as  it  lay  directly  in  the  course  of  a  large  vein  running  up  to  the  lesser  curvature. 

The  patient  did  remarkably  well  until  one  week  after  operation,  when,  with  only  a  few 
minutes  warning,  he  vomited  a  pus-basin  full  of  bright  red  blood.  This  was  the  first  time 
he  had  vomited  since  the  transfusion  over  two  weeks  previously.  He  continued  to  vomit 
blood  the  entire  day,  though  morphin,  horse  serum,  etc. ,  were  pushed  to  the  limit.  .A  donor 
being  at  last  secured,  a  second  blood  transfusion  was  attempted,  but  the  patient  succumbed 
thirty  minutes  after  its  termination. 

.\t  autopsy  numerous  ulcerations,  varying  in  size  from  a  pinhead  to  a  pea,  were 
found,  involving  only  the  mucous  membrane  of  the  stomach,  in  the  region  of  the 
pylorus,  and  mostly  on  its  posterior  wall.  No  single  lesion  could  be  identified  as  the 
source  of  the  hemorrhage.     The  anastomosis  was  intact. 

Bleeding,  more  moderate  in  amount,  though  perhaps  still  alarming 
at  times,  but  which  ceases  before  the  patient  is  entirely  prostrated, 
and  again  recurs  in  similar  amounts  at  irregular  intervals  of  a  few 


82  GASTRIC  ULCER 

weeks  or  months,  is  the  form  of  hemorrhage  which  is  specially  charac- 
teristic of  the  round  open  ulcer.  In  such  cases  the  ulceration  in  its 
progress  opens  some  medium  sized  arterial  twig,  and  free  hemorrhage 
occurs  until  retraction  and  contraction  of  the  opened  vessel  allow  its 
mouth  to  be  closed  by  clotting.  \'enous  twigs  are  more  rarely  opened 
by  these  ulcers,  possibly  because  the  current  of  blood  in  them  is  slower, 
the  tension  less,  and  clotting  occurs  before  or  as  soon  as  the  vessel  is 
opened.  When  repeated  vomitings  are  merely  streaked  with  blood, 
the  hemorrhage  has  probably  arisen  in  some  such  way  as  this.  The 
callous  ulcer  has  as  its  characteristic  form  of  bleeding  the  "occult" 
hemorrhage  already  mentioned.  The  area  of  the  stomach  affected  is 
in  these  cases  anemic,  being  very  largely  formed  of  scar  tissue,  and  any 
bleeding  that  occurs  usuallj'  comes  from  some  abrasion  of  the  stomach 
wall  consequent  upon  the  stenosis  present.  But  if,  in  this  form  of  ul- 
ceration, a  blood  vessel  of  any  size  is  perforated,  the  very  thickness  and 
rigidity  of  the  margins  of  the  ulcer,  which  were,  before,  the  patient's 
protection  against  hemorrhage  and  perforation,  promote  now  his 
destruction,  since  they  absolutely  prevent  retraction  and  contraction 
of  the  opened  vessel,  and  bleeding  continues  until  the  patient  is  dead. 
It  is  by  such  a  process  as  this  that  the  splenic  or  hepatic  artery  or  one 
of  their  branches  occasionally  is  perforated,  the  chronic  ulcer  having 
long  since  contracted  adhesions  to  the  pancreas  or  its  surrounding 
structures,  and  the  artery  being  fixed  in  a  vise  of  cicatricial  connective 
tissue. 

Hemorrhage  from  an  ulcer  of  the  stomach  ii  not  always  manifested 
by  vomiting.  In  some  cases  of  profuse  hemorrhage  the  patient  sud- 
denly turns  pale,  becomes  giddy,  gasps  for  breath,  is  exceedingly 
thirsty;  his  pulse  becomes  feeble  and  rapid,  his  stomach  feels  full 
and  warm,  and  sj'ncope  may  be  followed  by  death  without  further 
warning.  If  the  bleeding  be  less  profuse,  and  still  no  vomiting  occur, 
Ufe  may  be  prolonged  for  a  couple  of  days,  the  patient  presenting,  after 
the  symptoms  of  internal  hemorrhage,  those  of  mild  sepsis,  with  fever 
and  dehrium.  Black  spots  may  float  before  the  eyes,  or  the  amblyopia 
maj'  be  complete. 

The  more  profuse  the  hemorrhage,  the  more  apt  it  is  to  be  due  to 
ulcer,  and  not  to  carcinoma  or  to  portal  congestion  or  gastritis.  In 
these  latter  conditions  the  amount  of  blood  lost  is  rarely  more  than 
50  to  75  cc,  and  usually  clots  before  being  vomited;  but  500  cc.  or 
more  is  not  infrequently  lost  in  cases  of  ulcer.  After  a  hemorrhage  of 
even  less  amount,  the  patient  may  present  the  signs  of  secondary 
anemia  for  some  weeks.     Dyspnea  may  occur  on  the  least  exertion; 


GASTRIC   PERFORATION  83 

the  extremities  may  remain  cold  and  clammy;  tinnitus  aurium  may  be 
an  annoying  feature;  restlessness  or  even  deliriurri  may  disturb  the 
sleep.  Irregular  fever  may  persist  in  some  patients  for  many  weeks. 
This  symptom,  although  always  arousing  suspicions  of  perigastric 
abscess,  may  be  due  to  mild  sepsis  from  a  sloughing  ulcer,  which  even  a 
successful  gastro-enterostomy  cannot  relieve  at  once,  or  may  possibly 
be  merely  an  evidence  of  the  severe  secondary  anemia. 

Perforation  of  Gastric  Ulcers 

This  serious  comphcation,  which  is  said  to  occur  in  about  four  per 
cent,  of  all  cases,^  and  to  constitute  eighty  per  cent,  of  the  deaths  due 
to  the  disease,  arises  from  various  and  rather  ill-defined  causes.  As  in 
the  case  of  hemorrhage,  so  also  a  perforation  may  be  inaugurated  either 
by  physical  means,  or  by  the  pathological  processes  of  ulceration  or 
sloughing.  When  an  acute  ulcer  is  subjected  to  sudden  strain,  as  in 
vomiting,  or  is  abraded  by  ingested  food,  its  base  may  give  way,  and 
the  peritoneal  cavity  be  opened.  Chronic  ulcers  are  not  so  apt  to  be 
affected  in  this  manner,  partly  because  of  the  thickness  of  their  bases 
and  margins,  but  more  especially  because  perigastritis  usually  has 
existed  for  some  time,  and  as  a  consecjuence  the  general  peritoneal 
cavity  is  protected  by  adhesions.  Adhesions  are  said  to  be  present  in 
about  two-fifths  of  the  cases  of  perforation.  When,  in  an  acute  ulcer, 
the  perforation  arises  from  the  physical  causes  just  mentioned,  the 
solution  of  continuity  is  frequently  slit-like  in  character;  but  when  due 
to  the  extension  of  the  ulcerating  process,  or  to  sloughing,  the  perfora- 
tion is  more  or  less  circular.  It  is  generally  found  that  the  larger  per- 
forations are  due  to  the  separation  of  a  slough,  and  that  those  produced 
by  progressing  ulceration  are  minute  in  size,  and  give  rise  to  symptoms 
less  acute  than  the  other  varieties  of  perforation. 

Perforations  vary  by  actual  measurement  from  those  which  can  be 
classed  merely  as  pin-point  to  those  which  will  admit  two  or  three 
fingers  and  measure  5  to  8  cm.  in  diameter.  The  average  perforation 
however,  does  not  exceed  3  to  5  mm.  in  diameter. 

As  a  rule  there  is  not  more  than  one  perforation  present;  but  in  about 
20  per  cent,  of  cases  two  or  more  have  been  found.  Hence  it  is  always 
well  to  search  the  gastric  surface  thoroughly,  and  in  cases  of  doubt  to 
establish  free  drainage  of  suspicious  regions. 

'  This  figure  should  be  much  higher  if  only  those  patients  with  gastric  ulcer  who  seek 
surgical  relief  are  considered;  in  a  series  of  44  operations  for  ulcer  of  the  stomach  at  the 
Lankenau  Hospital,  g  perforations  (7  acute,  2  subacute)  were  encountered  (20.4  per  cent.). 


84 


GASTRIC  ULCER 


About  70  per  cent,  of  perforations  are  on  the  anterior  wall  of  the 
stomach;  and  those  situated  on  the  anterior  wall  toward  the  pyloric  end 
and  near  the  lesser  curvature  form  about  So  per  cent,  of  the  total. 
About  18  per  cent,  occur  on  the  posterior  wall;  while  the  fundus  and 
cardia  are  very  rarely  the  seat  of  perforation.  The  anterior  wall  of 
the  stomach  is  exposed  to  the  general  peritoneal  cavity,  is  subject  to  a 
greater  degree  of  dilatation  and  contraction  than  is  the  posterior,  and 
is  also  more  exposed  to  external  trauma  acting  through  the  abdominal 
walls.     The  posterior  wall  is  placed  in  contact  with  the  relatively 

rigid    and    immovable    spinal 

-  Anr  \      \    X  \         column,  within  the  limited  con- 

O  -Posr  \  \      tines    of    the    lesser   peritoneal 

cavity,  and  in  close  relation 
with  the  pancreas,  duodenum, 
and  Spigelian  lobe  of  the  liver. 
Being  thus  protected,  ulcers  on 
the  posterior  gastric  surface  are 
prone  to  induce  perigastric  ad- 
hesions as  soon  as  any  peri- 
toneal irritation  is  developed, 
and  being  so  reinforced  are 
neither  so  apt  to  perforate,  nor 
to  produce  diffuse  peritonitis 
in  the  rare  event  of  their  actual 
perforation,  as  are  those  placed 
The  location  of  gastric  perforations 


Pig.  34. — Diagram  of  Sites  of  25  Perforated 
Gastric  and  Duodenal  Ulcers  Operated  on  by  the 
Senior  Author  at  the  Lankenau  Hospital.  Per- 
forations on  the  Posterior  .^Wall^  are  Indicated 
by  a  Dotted  Outline. 


in  less  well-protected  situations, 
is  well  shown  in  Fig.  34. 

Perforation  of  gastric  ulcers  has  been  well  described  as  acule. 
subacute,  or  chronic  in  character.  These  terms  refer  not  so  much  to 
the  symptoms  produced,  as  to  the  pathological  course  of  the  peritonitis 
caused  by  the  perforation.  An  ulcer  which  perforates  acutely  is  one 
such  as  those  on  the  anterior  wall  which  bursts  through  into  the 
peritoneal  cavity  by  sloughing  or  from  the  eft'ect  of  physical  forces, 
without  having  previouslj'  set  up  by  contiguity  a  limited  plastic  peri- 
tonitis sufficient  to  protect,  for  a  time  at  least,  the  general  peritoneum 
from  invasion.  An  ulcer  which  perforates  subacutely  is  one  whose 
base  is  gradually  ulcerated  through,  so  that  perigastritis  with  its  pre- 
monitory symptoms  precedes  the  actual  solution  of  continuity;  and 
so  that  when  this  solution  of  continuity  occurs,  there  is  either  a  spreading 
plastic  peritonitis  already  inaugurated,  or  adhesions  are  present  which 
are  more  or  less  capable  of  limiting  the  outflow  of  the  gastric  contents. 


GASTRIC   PERFORATION  85 

By  the  term  chronic  perforation  is  inidcated  that  process  which  ensues 
when  the  base  of  an  ulcer  is  adherent  to  some  neighboring  organ,  so 
that  scarcely  any  additional  s3Tnptoms  are  produced  at  the  actual 
moment  when  the  gastric  wall  ceases  to  form  the  floor  of  the  ulcer,  and 
its  place  is  taken  by  pancreatic  or  hepatic  tissue,  or  by  firm  fibrino- 
plastic  material — so  that,  in  short,  the  symptoms  which  first  call 
attention  to  the  changed  condition  are  not  those  of  perforation  nor 
peritonitis,  but  of  sepsis,  induced  by  slow  absorption  from  some  variety 
of  perigastric  or  subphrenic  abscess. 

Subphrenic  abscess  (Chapter  XV)  has  as  one  of  its  most  frequent 
causes  gastric  ulcer.  The  term  subphrenic  abscess,  so  indiscriminately 
used  is  in  many  instances  a  misnomer,  since  the  purulent  collection  is 
used,  frequently  subhepatic  or  retrocolic  in  location,  and  bears  no 
direct  relation  to  the  diaphragm.  • 

Symptoms. — The  initial  symptoms  of  perforation  of  any  portion  of 
the  digestive  tract  bear  a  family  resemblance  to  each  other,  and  it  is 
mainly  by  attention  to  the  previous  history  of  the  case,  and  to  certain 
rather  ill-defined  differential  points,  that  a  decision  can  be  reached  as 
to  the  particular  part  affected.  Premonitory  symptoms  are  not 
unusual,  as  pointed  out  by  Robson  and  Moynihan.  Recently  one  of 
us  (Ashhurst)  examined  a  woman  at  noon,  who  for  a  couple  of  days 
had  been  complaining  of  a  stitch  in  the  si^e — all  her  symptoms  being 
referred  to  the  left  lower  thorax  and  flank:  examination  was  negative. 
Three  hours  later  she  developed  symptoms  of  acute  perforation,  the 
ulcer  being  found  at  operation  along  the  lesser  curvature  on  the  anterior 
wall  near  the  cardia. 

Sudden,  severe,  burning  pai)i  is  nearly  invariably  the  first  symptom. 
It  is  usually  localized  in  the  epigastric  or  umbilical  region,  showing  no 
tendency  to  shoot  from  one  portion  of  the  belly  to  another,  nor  to  be 
referred  to  the  hypochondriac  or  scapular  regions.  The  pain  is  fre- 
quently so  severe  as  to  compel  the  patient  to  cry  out;  it  affects  him  like 
a  cramp:  he  doubles  up  his  thighs  toward  his  abdomen,  and  bows  his 
body  to  his  thighs,  pressing  his  hands  into  his  belly.  Any  one  who  has 
watched  even  one  of  these  patients  will  never  forget  the  sight.  This 
agonizing  pain  may  persist  for  fifteen  or  thirty  minutes;  seldom  is 
it  succeeded  by  symptoms  of  shock.  Shock,  recognized  by  the 
anxious  cast  of  countenance,  the  cold  and  clammy  surface,  the  pallor, 
the  guarded  breathing,  and  the  quickening,  feeble  pulse  occurs  only 
when,  through  a  perforation  of  extraordinary  size,  an  overwhelming 
amount  of  highly  toxic  material  is  suddenly  poured  forth  into  a 
normal  peritoneal  cavity.     It  is  due  then  to  the  toxemia  produced  by 


_86  GASTRIC  ULCER 

sudden  absorption  from  the  peritoneal  cavity  of  toxins  and  metabolic 
poisons  in  the  effused  gastric  contents. 

Usually,  when  first  seen  by  the  physician,  the  most  acute  symptoms 
have  already  passed,  and  the  patient  lies  immobile  on  one  side,  or  on 
his  back  with  his  legs  drawn  up,  carefully  guarding  the  abdomen. 

After  the  first  onset  of  pain,  the  patient  often  (in  from  fifty  to 
sixty  per  cent,  of  cases)  vomits,  but  this  act  is  not  commonly  repeated, 
thus  giving  us  one  important  point  of  distinction  between  perforation 
and  obstruction  or  strangulation  of  the  bowel.  Vomiting  is  a  serious 
feature,  since  it  forces  the  stomach  contents  out  not  only  by  way  of 
the  esophagus,  but  also  through  the  perforation  into  the  peritoneal 
cavity.  If  the  stomach  be  empty  at  the  time  perforation  occurs,  the 
nausea  will  produce  retching  only,  and  at  most  a  little  fluid,  occa- 
sionally blood-stained,  will  be  vomited. 

Marked  rigidity  of  the  abdominal  wall  appears  almost  immediately, 
and  its  "board-like"  character  is  especially  characteristic  of  frank 
perforation;  such  board-like  rigidity  is  seen  also  in  gross  perforations 
of  the  appendLx,  intestines,  or  gall-bladder;  but  not  in  peritonitis  of 
slower  onset  not  caused  by  gross  perforations.  If  the  infection  be 
overwhelming,  however,  rigidity  may  never  appear,  but  the  patient 
will  sink  under  the  lethal  influence  of  the  toxic  peritonitis,  without  an 
effort  at  repair  of  the  lesion  by  plastic  exudation.  Tenderness  arises 
at  the  same  time  as  rigidity.  The  patient  will  no  longer  feel  the  pain 
as  a  cramp-like  aft'ection;  he  will  draw  up  his  thighs  so  as  to  relax 
the  abdominal  muscles,  and  will  protect  his  belly  from  the  sUghtest 
pressure.  The  tenderness  thus  developed  may  persist  after  extensive 
peritoneal  involvement  with  its  consequent  tympany  has  rendered 
rigidity  inappreciable.  Of  the  two  symptoms,  however,  rigidit)'  is  the 
more  positive.  Distention  and  tympany  develop  only  with  the  progres- 
sive course  of  the  peritonitis,  and  thus  are  late  signs  of  perforation, 
replacing  the  original  very  characteristic  rigidity  only  toward  the  tenth 
or  eleventh  hour. 

Thirst  is  a  very  frequent  symptom  of  gastro-intestinal  perforations. 
Although  nausea  be  present,  and  even  if  the  initial  vomiting  be  re- 
peated, the  patient  will  be  very  apt  to  drink  water  time  and  again,  in 
the  vain  e&"ort  to  relieve  his  thirst.  During  the  height  of  the  attack 
the  urine  is  scanty  or  altogether  suppressed. 

Emphysema  of  the  subcutaneous  tissues,  a  very  unusual  and  a 
very  late  symptom,  is  said  to  have  been  first  noted  in  a  case  of  gastric 
perforation  by  Demarquay  (1866). 

Immediately  after  perforation  of  any  portion  of  the  gastro-intestinal 


GASTRIC   PERFORATION  87 

tract,  the  temperalure  is  apt  to  fall.  We  attach  considerable  importance 
to  this  symptom,  and  believe  that  if  the  temperature  were  taken  without 
fail  immediately  after  the  initial  pain  appeared,  it  would  be  found 
subnormal  with  greater  regularity  than  the  statements  of  some  writers 
would  lead  one  to  believe. 

Accompanying  or  closely  following  the  fall  of  temperature,  there 
is  a  quickening  of  the  pulse;  and  if  operation  be  not  undertaken 
promptly,  the  local  tenderness  and  rigidity  will  spread  over  the  ab- 
domen. We  have  seen  a  very  few  cases  in  which  the  pulse  was  full 
and  strong,  and  its  rate  slow.  Whether  this  has  any  significance  we 
do  not  know.     (  See  p.  596  and  p.  643.) 

Diagnosis. — Acute,  overwhelming  pain,  vomiting,  fall  of  temper- 
ature, rise  of  pulse,  and  peritoneal  reaction,  i.e.,  early  rigidity,  followed 
from  ten  to  eleven  hours  later  by  distention — these  are  the  symptoms 
of  perforation  into  the  peritoneal  cavity  in  general;  and,  as  was  re- 
marked in  the  beginning,  it  remains  to  determine  in  the  presence  of 
these,  what  portion  of  the  gastro-intestinal  tube  is  affected. 

The  surgeon's  thoughts  naturally  turn  to  gastric  or  duodenal  ulcer 
as  the  cause  of  the  perforation,  and  ninety-nine  times  out  of  one  hundred 
he  would  be  correct,  even  in  the  absence  of  a  history  of  gastric  disease. 
Such  history  usually  can  be  elicited  in  from  50  to  75  per  cent,  of  patients. 

The  diagnosis  in  typical  cases  is  easily  made  by  the  hospital  interne 
of  average  intelligence,  from  the  text-book  descriptions.  Yet  if  the 
cases  are  seen  late,  it  is  not  always  easy  to  make  the  correct  diagnosis. 
Thus  in  a  series  of  59  cases  from  the  Cook  County  Hospital,  studied  by 
Scully  (191 8),  only  5  of  which  came  to  operation  in  less  than  5  hours 
after  onset  of  symptoms,  a  correct  diagnosis  was  made  only  in  27 
cases  (45.7  per  cent).     The  other  diagnoses  were: 

Acute  appendicitis 9 

Acute  cholecystitis 3 

"Acute  abdomen" 17 

Ileus 2 

Liver  abscess i 

Correct 27 


59 


In  an  adult  man,  duodenal  ulcers  are  more  apt  to  be  the  cause  of 
perforation  than  are  gastric,  and  where  no  history  is  obtainable,  that 
portion  of  the  digestive  tract  should  be  explored  first  in  such  patients. 


88  GASTRIC  ULCER 

Of  course  if  there  is  a  clear  history  of  preceding  gastric  sj'mptoms,  it  is 
difficult  for  no  one  to  make  the  diagnosis  of  gastric  or  duodenal  per- 
foration; but  in  the  absence  of  such  history  there  are  no  pathogno- 
monic symptoms  by  which  we  can  certainly  distinguish  between  per- 
foration occurring  in  the  upper  and  that  occurring  in  the  lower  portions 
of  the  abdomen.  Those  portions  of  the  gastro-intestinal  tract  which 
most  frequently  perforate  are  the  appendix,  the  duodenum,  the  stomach 
and  the  ileum,  and  the  frequency  of  perforation  is  probably  in  the 
order  named.  But  perforation  of  the  appendix  is  rare  compared  to  the 
development  of  peritonitis  from  appendicitis  without  macroscopic 
perforation,  and  even  when  it  does  perforate  into  the  general  peritoneal 
cavity,  the  symptoms  produced  are  not  of  so  alarming  and  prostrating  a 
nature  as  when  some  portion  of  the  digestive  tube  with  a  larger  calibre 
is  perforated,  even  when  a  large  perforation  occurs  at  the  base  of  the 
appendix.  Perforations  of  the  ileum  are  rare,  except  during  t)T)hoid 
fever;  and  the  occurrence  of  symptoms  of  peritoneal  perforation  during 
typhoid  fever  naturally  suggest  the  ileum  as  the  part  affected. 
Typhoid  ulcers  of  the  stomach  are  extremely  rare. 

In  diagnosticating  perforations  of  the  upper  abdomen,  when  the 
clinical  history  is  negative,  we  must  rely  chiefly  upon  the  location  of  the 
initial  pain,  upon  the  excessive  board-like  rigidity  (rarely  seen  in 
appendicitis  even  with  diffuse  peritonitis),  and  upon  the  directions  in 
which  peritoneal  involvement  proceeds.  Although  perforations  in 
other  portions  of  the  abdomen  sometimes  produce  epigastric  pain,  it  is 
rare  for  gastric  perforations  to  cause  other  than  epigastric  pain.  Then, 
too,  in  gastric  and  duodenal  perforations,  the  general  peritoneal  cavity 
is  more  quickly  involved  than  in  perforative  lesions  of  the  lower  abdo-. 
men.  In  the  latter  it  is  the  pelvis  that  is  usually  first  involved  by 
extension,  and  the  umbilical  and  epigastric  regions  do  not  become 
affected  until  later;  whereas  when  the  perforation  is  in  the  stomach  or 
duodenum,  these  regions  are  immediately  affected,  and  it  is  only  by 
gravitation  of  liquids  that  the  lower  portions  of  the  abdomen  are  in- 
volved. In  the  majority  of  gastric  perforations  the  transverse  colon 
and  the  great  omentum  protect  the  hypogastric  region  and  the  pelvis 
from  invasion,  and  as  the  splenic  flexure  of  the  colon  is  higher  than  the 
hepatic,  any  fluid  extravasated  above  it  tends  to  flow  toward  the  right. 
These  facts,  as  well  as  the  anatomical  relations  of  the  ascending  meso- 
colon, tend  to  make  fluids  from  perforations  in  the  upper  abdomen 
collect  first  in  the  right  kidney  pouch,  and  then  in  the  right  iliac  fossa 
following  the  paracolic  groove.  \Mien  a  j)aticnt  presents  such  symp- 
toms as  these  when  seen  for  the  first  time,  the  resemblance  to  appendicu- 


GASTRIC   PERFORATION  89 

lar  abscess  is  very  close,  and  the  diagnosis  of  gastric  perforation  is 
scarcely  ever  made  before  operation,  "especially  where  no  history  of 
previous  gastric  disease  can  be  elicited. 

In  some  instances,  when  the  existence  of  a  gastric  ulcer  is  known, 
the  onset  of  a  subacute  perforation  may  be  recognized  by  premonitory 
symptoms  for  several  days  beforehand.  Fleeting  pain  of  a  stab-like 
character,  or  merely  vague  feelings  of  increased  gastric  distress  may 
be  present;  and  cases  are  known  where  deep  breathing  or  sudden 
turning  of  the  body  have  caused  exacerbations  of  the  pain  by  a  sudden 
pull  on  newly  formed  adhesions.  Robson  and  Moynihan  mention  a 
patient  who  said  that  it  hurt  her  to  bend,  as  her  side  felt  stiff.  In 
cases  such  as  these  the  moment  of  actual  perforation  is  not  attended 
by  such  violent  pain  nor  by  such  marked  collapse  as  when  the'  per- 
foration is  acute;  and  a  temporary  lull  may  occur,  during  which  the 
symptoms  abate,  and  a  perigastric  abscess  forms.  Unless  promptly 
relieved  by  operation  such  patients  will  perish  from  sepsis  or  from 
subsequent  generalized  peritonitis. 

The  symptoms  of  chronic  perforations  of  the  stomach  are  those  of 
perigastric  and  subphrenic  abscess.  Strict  attention  to  the  clinical 
history  of  the  patient,  with  a  painstaking  and  if  need  be  oft-repeated 
physical  examination  will  enable  the  diagnosis  to  be  made  in  the 
majority  of  cases.  Evidences  of  sepsis,  with  progressive  emaciation, 
hectic  fever,  chills  and  sweats,  and,  above  all,  persistent  tenderness  to 
pressure  will  be  the  surgeon's  best  guide.  Further  consideration  is 
given  this  subject  in  Chapter  XV. 

DiJJerential  Diagnosis. — Although,  with  a  clear  history  and  char- 
acteristic symptoms,  such  as  those  already  detailed,  the  diagnosis  of 
gastric  perforation  may  be  considered  an  easy  problem,  yet  in  not  a 
few  instances  mistakes  have  been  made  by  capable  surgeons.  Even 
with  symptoms  so  typical  as  to  leave  no  reasonable  room  for  doubt, 
abdomens  have  been  opened,  and  yet  no  lesion  whatever  has  been 
found,  and  the  patients  have  gone  on  to  satisfactory  recovery.  And 
in  a  somewhat  less  limited  number  of  cases  some  lesion  other  than 
gastric  perforation  has  been  discovered  either  at  operation  or  autopsy. 
The  importance  of  attentively  considering  the  differential  diagnosis  of 
this  complication  is  therefore  very  evident. 

Perforation  of  duodenal  ulcer  is  the  condition  which  in  every  respect 
most  closely  resembles  the  perforation  of  a  gastric  ulcer.  Indeed,  so 
close  is  the  resemblance  that  differentiation  from  symptoms  alone  is 
usually  impossible,  and  the  surgeon  must  rely  on  the  age,  sex,  and 
previous  history  of  the  patient  in  drawing  his  conclusions.     Since 


90  GASTRIC  ULCER 

immediate  operation  is  indicated  in  either  case,  the  distinction  in  this 
instance  is  rather  of  academic  than  practical  importance. 

Though  rare,  it  is  not  an  unheard  of  thing  for  peritonitis  to  arise 
in  gastric  disease  without  any  actual  perforation.  McCosh  (1900) 
recorded  the  case  of  a  patient  in  whom  strangulation  of  a  gastric 
polyp  produced  gangrenous  gastritis,  with  the  formation  of  an  abscess 
which  gravitated  to  the  right  iliac  fossa,  and  later  caused  death  from 
general  peritonitis.  Harte  (1901)  observed  a  case  in  which  a  septic 
gastritis,  arising  during  an  attack  of  acute  nephritis,  with  uremia, 
caused  all  the  symptoms  of  a  gastric  or  duodenal  perforation,  and  in 
which  death  ensued  from  generalizd  peritonitis,  no  macroscopic 
perforation  being  discoverable  at  autopsy. 

Acute  appendicitis  differs  in  several  respects  in  the  symptoms  it 
usually  presents,  and  as  a  rule  need  not  be  confused  with  a  gastric 
perforation,  especially  if  the  latter  be  of  the  acute  variety,  Many 
cases  of  subacute  perforation  of  the  stomach  resemble  suppurative 
appendicitis  very  closely,  and  are  frequently  not  to  be  distinguished 
until  after  the  abdomen  has  been  opened.  In  acute  appendicitis  the 
initial  pain  is  diffuse,  colicky,  and  wave-like  in  character;  at  a  later 
period  it  settles  into  the  right  iliac  fossa.  There  is  little  if  any  collapse; 
fall  of  temperature  is  rare;  abdominal  rigidity  is  well  localized  to  the 
region  of  the  appendix,  and  general  peritoneal  invasion  is  often  delayed 
for  one  or  two  days,  a  palpable  mass  meantime  forming  in  the  right 
iliac  fossa.  The  pain  in  acute  gastric  perforation  is  overwhelming, 
and  though  local  at  first,  very  quickly  becomes  general;  shock  may  be 
present,  though  rare,  the  temperature  may  fall,  and  the  patient  may 
appear  in  imminent  danger  of  death;  there  is  widespread,  board-like 
rigidity  at  tirst,  but  as  reaction  commences,  evidences  of  general 
peritonitis  are  found,  at  a  much  earlier  period  than  is  the  case  in 
appendicitis.  Some  cases  of  appendicitis,  however,  so  closely  resem- 
ble a  gastric  or  duodenal  perforation,  that  differentiation  is  impossible. 
Especially  is  this  true  in  the  case  of  large  perforations  at  the  base 
of  the  appendix,  and  sometimes  in  the  case  of  a  ruptured  appendicular 
abscess. 

Ruptured  extrauterine  pregnancy  resembles  gastric  perforation  in 
the  agonizing  pain.  But  the  previous  histories  are  different;  the  loca- 
tion of  the  pain  is  not  the  same;  evidences  of  internal  hemorrhage 
frequently  persist,  and  overshadow  the  rather  tardy  development  of 
peritonitis;  and  a  vaginal  examination  may  detect  an  exquisitely  tender 
tumor  in  the  pelvis.     Occasionally  there  is  profound  collapse. 

Acute  intestinal  obstruction  is  not  characterized  by   symptoms  of 


GASTRIC    PERFORATION  QI 

peritonitis  until  strangulation  occurs.  Vomiting  is  persistent,  be- 
coming stercoraceous  in  time;  rigidity  is  not  pronounced,  and  relief 
from  the  pain  may  even  be  obtained  by  pressure  and  massage  of  the 
abdomen  at  a  time  long  after  diffuse  peritonitis  would  have  arisen 
were  the  case  one  of  gastric  perforation.  Obstipation  usually  is 
absolute;  collapse  is  wanting  unless  perforation  occurs  above  the 
strangulated  area,  and  the  temperature  remains  normal  or  subnormal 
until  the  advent  of  peritonitis.  The  previous  history  of  the  patient 
may  reveal  the  cause  of  the  obstruction  in  long-standing  peritoneal 
adhesions,  or  physical  examination  may  detect  a  strangulated  hernia 
or  an  ill-defined  abdominal  tumor — possibly  a  volvulus,  an  intussus- 
ception, or  a  pelvic  tumor  with  twisted  pedicle. 

Gall-stone  colic  and  acute  cholecystitis  are  usually  sufficiently 
distinguished  by  their  clinical  history,  the  location  of  their  physical 
signs,  with  the  slower  development  of  peritonitis. 

Acute  hemorrhagic  pancreatitis  resembles  gastric  perforation  in  the 
intensity  of  the  pain  but  no  history  of  gastric  ulcer  is  as  a  rule  obtain- 
able, and  the  typical  subjects  of  pancreatitis  are  obese,  alcoholic  in- 
dividuals of  middle  life  while  gastric  perforations  are  comparatively 
rare  after  the  age  of  30  years.^  There  may  be  palpable,  in  the  region 
of  the  pancreas,  a  deep  seated  tumor,  which  does  not  move  with 
respiration,  and  which  may  reveal  an  indistinct  sense  of  fluctuation. 
These  features  somewhat  resemble  those  which  arise  in  cases  of  peri- 
gastric abscess  or  empyema  of  the  bursa  omentalis,  due  to  subacute 
or  chronic  perforations  of  gastric  ulcers;  and  though  some  assistance 
in  making  the  diagnosis  may  be  obtainable  by  the  possible  occur- 
rence, in  pancreatitis,  of  jaundice,  fatty  diarrhea,  and  glycosuria, 
yet  in  many  cases  differentiation  before  opening  the  abdomen  is 
impossible. 

Mesenteric  thrombosis  is  another  affection  which  is  sometimes  con- 
fused with  perforation  of  gastric  ulcers.  It  is,  however,  a  compara- 
tively rare  occurrence;  and  is  not  characterized  by  abrupt  onset, 
nor  by  early  peritonitis.  Indeed,  when  the  thrombosis  is  arterial, 
there  are  no  well-recognized  symptoms  by  which  a  diagnosis  can  be 
made,  the  affected  bowel  becoming  the  seat  of  dry  gangrene.  If 
venous  obstruction  arises,  the  symptoms  are  more  acute:  there  are 
vague  abdominal  pains,  continuous  but  paroxysmal;  a  little  fever, 
possibly  vomiting;  sometimes  bloody  stools;  and  finally  the  evidence 
of  peritonitis.  But  the  course  is  much.  less  acute  than  in  gastric  per- 
forations, and  all  the  S5miptoms  less  severe. 

'  The  junior  author  has  operated  on  a  man  84  years  of  age  with  duodenal  perforation. 


92  GASTRIC  ULCER 

Ptomaiii  poisoning  is  characterized  by  a  similar  onset — acute  abdom- 
inal pain,  nausea,  and  vomiting,  but  often  these  are  followed  by  collapse, 
which  may  be  great,  the  temperature  subnormal,  and  the  skin  cold  and 
clammy.  Diarrhea,  moreover,  is  often  a  sahent  feature,  and  the  vomiting 
is  more  persistent  than  in  cases  of  gastric  perforation.  Although  the 
physical  signs — tenderness,  rigidity,  followed  by  distention — are  the  same 
in  both  aiiections,  distention  occurs  much  earlier  in  ptomain  poisoning 
than  when  due  to  peritonitis  from  gastric  perforation.  In  ptomain 
poisoning,  also,  a  history  of  the  ingestion  of  suspected  food  stuffs  can 
usually  be  obtained;  and  a  period  of  incubation  (varying  from  twelve 
to  thirty-six  or  forty-eight  hours)  between  the  ingestion  of  the  poison 
and  the  development  of  symptoms  will  usually  be  found  to  have 
elapsed.  During  this  period  of  incubation  the  patient  may  have  been 
seemingly  well,  or  there  may  have  been  fleeting  pains  in  the  abdomen, 
and  more  or  less  vnilaise.  This  distress,  however,  is  intestinal,  not 
gastric;  and  the  history  does  not  in  the  least  resemble  that  of  gastric 
ulcer. 

Skin  Diseases. — Certain  affections  of  the  skin,  whose  pathology 
is  still  ver\'  obscure,  are  at  times  attended  by  gastro-intestinal  crises. 
This  is  particularly  true  of  those  aft'ections  belonging  to  the  en,-thema 
group,  and  while  they  are  more  common  in  children,  in  whom  gastric 
perforations  are  extremely  rare,  they  are  not  unknown  among  adults. 
The  occurrence  of  purpura,  angeio-neurotic  edema,  erj-thema,  or 
urticaria,  with  recurring  cohc,  and  often  albumen  in  the  urine,  are  the 
symptoms  most  significant. 

Gastric  crises  of  tabes  dorsalis  should  be  kept  in  mind  in  at}T.iical 
cases.  Neglect  of  a  complete  physical  examination  has  several  times 
mislead  a  surgeon  in  these  patients. 

Diagnosis  in  C.\ses  of  Gastric  Ulcer 

It  scarcely  seems  necessary,  after  the  account  of  the  affection  just 
given,  to  dwell  at  any  great  length  upon  its  diagnosis.  Yet  this  is  not 
always  an  easy  matter,  in  spite  of  the  succinctness  v,iih  which  the 
symptoms  may  be  detailed.  The  clinical  history  of  the  patient  is  the 
feature  of  the  disease  which  is  most  constant,  and  which  must,  in  our 
judgment,  take  precedence  over  the  physical  examination,  and  over 
diagnosis  by  means  of  laboratorj^  methods,  and  skiagraphy.  Too  little 
attention  is  commonly  paid  both  by  the  family  physician  and  the 
consultant  to  the  importance  of  cUciting  a  clear  and  untrammeled 
account  of  the  origin  and  progress  of  the  malady  from  which  the  patient 


DIAGNOSIS  93 

suffers.  In  cases  of  doubt,  the  attendant  should  return  to  the  charge 
again  and  again,  and  should  endeavor,  without  putting  upon  the 
patient's  tongue  any  false  answers,  to  obtain  from  him  such  responses 
as  will,  when  strung  together  in  chronological  order,  reveal  the  natural 
course  of  the  disease.  Very  many  patients  will  have  forgotten  the 
earliest  symptoms  from  which  they  suffered  because  they  were  ignorant 
of  their  significance;  and  it  may  not  be  until  they  have  been  questioned 
two  or  three  times  that  some  event,  such  as  slight  hematemesis,  seem- 
ingly trivial  in  itself,  will  rise  again  to  their  memory,  and  perhaps 
supply  to  the  history  of  the  disease  the  missing  link  which  so  long  had 
been  desired.  The  diagnostician  never  should  forget  that  the  presence 
of  one  or  two  positive  signs  is  worth  infinitely  more  than  the  absence  of 
many  others. 

The  features  of  most  value  in  the  clinical  history  of  the  patient 
have  been  tabulated  under  the  following  heads  by  C.  Graham  (1913): 

1.  Periodicity  oj  attacks  of  "indigestion"  is  especially  characteristic 
of  gastric  (pyloric  and  duodenal)  ulcers.  These  patients  suffer  for 
several  days  or  weeks  at  a  time  with  stomach  symptoms  (flatulence, 
pain,  belching,  etc.)  and  then  for  an  indefinite  period  (usually  for  weeks 
or  months)  are  almost  if  not  entirely  free  from  any  discomfort.  These 
recurrent  attacks  show  a  special  predilection  for  the  spring  and  autumn 
of  the  year,  and  seem  to  be  brought  on  sometimes  by  worry,  overwork, 
or  some  intercurrent  infection  (coryza,  grippe,  bronchitis,  etc.). 

2.  Chronicity  of  the  Disease.  The  train  of  symptoms  above  noted 
usually  has  lasted  for  years  before  the  distress  becomes  severe  enough 
to  demand  relief. 

3.  Pain,  which  has  already  been  described  in  detail,  is  the  most 
constant  symptom  during  the  attack. 

4.  Time  and  control  oj  pain  are  also  very  characteristic.  Pain 
appears  after  eating;  in  duodenal  ulcer  it  may  appear  so  long  after 
eating  that  it  is  regarded  as  "hunger  pain,"  i.e.,  occurring  hejore  the 
next  meal.  Then  the  fact  that  this  pain  is  controlled  by  more  food,  by 
alkalies,  by  position,  or  by  rest  (vacation)  is  one  of  its  most  notable 
features.  Graham  thinks  that  the  nearer  the  ulcer  is  to  the  gastric 
outlet  the  longer  is  the  interval  between  ingestion  of  food  and  devel- 
opment of  pain.  But  this  means  of  localizing  an  ulcer  close  to  or  dis- 
tant from  the  pylorus  is  very  unreliable. 

The  physical  examination  must  be  considered  as  merely  confirma- 
tory of  the  clinical  history,  as  previously  elicited;  and  any  chemical  tests 
of  the  stomach  contents  are  of  value  only  as  corroborating  the  physical 
examination,  as  are  also  the  results  of  Roentgenological  study.     Indeed 


94  GASTRIC  ULCER 

most  Roentgenologists  do  not  attempt  to  make  any  diagnosis  from  their 
examinations  except  after  careful  study  of  the  clinical  history. 

Blood  examination  may  further  confirm  the  diagnosis  by  revealing 
a  chronic  anemia.  Friedman  (1914)  attempted  a  differential  diagnosis 
between  pyloric  and  non-pyloric  ulcer,  duodenal  ulcer,  and  chronic 
appendicitis,  on  the  basis  of  the  morphology  of  the  blood,  especially 
the  differential  leukocyte  count.  It  is  said  that  the  presence  of  the 
normal  leukocytosis  during  digestion  favors  the  diagnosis  of  ulcer 
rather  than  carcinoma. 

Differential  Diagnosis. — There  are  few  affections  with  which  a  case 
of  uncomjilicated  gastric  ulcer  need  be  confused.  An  exception  to 
this  statement  is  ulcer  oj  the  duodenum,  which  in  many  respects  may  so 
closely  resemble  gastric  ulcer  as  to  be  indistinguishable.  Its  symptom- 
atology is  considered  in  Chapter  VIII. 

Acute  gastritis  and  gastro-duodeiial  catarr/i,  while  possibly  pro- 
ductive of  the  symptoms  of  pain,  tenderness  and  vomiting,  are  affec- 
tions which  may  almost  always  be  traced  to  some  recent  indiscretion  in 
diet.  The  vomiting  does  not  recur  with  any  regularity  after  meals,  in 
the  effort  to  relieve  the  stomach  of  the  pain  which  is  present  in  cases  of 
ulcer,  but  is  the  result  of  nearly  constant  nausea,  which  is  character- 
istic of  the  inflammatory  nature  of  the  affection.  The  tendernes,  if 
any  is  present,  is  diffuse,  not  accurately  localized,  as  is  usual  in  cases 
of  gastric  ulcer;  hematemesis  occurs  only  in  the  most  exceptional 
cases;  and  jaundice,  which  is  extremely  rare  in  simple  gastric  ulcer,  is 
a  frequent  accompaniment  of  gastro-duodenal  catarrh.  Finally., 
abstinence  from  food,  with  other  appropriate  treatment,  quickly 
relieves  the  inflammatory  affection,  while  the  symptoms  of  gastric 
ulcer  persist,  or  if  cured  temporarily  are  prone  to  recur  as  soon  as 
energetic  treatment  is  discontinued. 

Hemorrhage  from  the  gastro-inlestinal  tract  tluc  to  other  causes 
than  gastric  ulcer  may  be  extremely  difficult  at  times  to  differentiate 
from  the  latter  affection.  Particularly  of  hematemesis  is  this  true. 
When  the  blood  is  discharged  from  the  bowel,  although  duodenal  ulcer 
should  certainly  be  considered,  there  are  usually  other  symptoms 
which  will  aid  the  diagnosis.  Enterorrhagia  is  sometimes  the  earliest 
symptom  of  typhoid  fever;  it  is  infreciucnt  as  an  early  symptom 
of  malignant  changes  in  the  bowel;  but  in  both  of  these,  as  in  almost 
every  other  conceivable  case  of  bleeding  from  the  bowels,  there  is 
almost  invariably  soon  developed  some  other  symptom  or  chain  of 
symptoms  which  at  once  makes  clear  the  nature  of  the  malady. 

Far    difi'erent    is   the   case   with   gastrorrhagia  and  hematemesis. 


DIFFERENTIAL    DIAGNOSIS 


95 


It  is  natural  to  assume  that  a  patient  presenting  these  symptoms 
suffers  from  gastric  ulcer;  and  when  all  other  lesions  have  been  ex- 
cluded, the  supposition  seems  justifiable.  The  confusion  of  hemop- 
tysis with  gastric  hemorrhage  is  not  usual,  and  the  difference  in  the 
physical  signs  between  the  gastric  and  thoracic  disease,  as  well  as  the 
frothy  character  of  the  expectorated  blood,  tend  to  make  such  con- 
fusion, if  it  ever  arise,  rather  short-lived. 

A  cause  of  sudden  profuse  hemorrhage  which,  until  recently,  has 
not  received  adequate  consideration,  is  the  rupture  of  varicose  veins 
of  the  stomach  or  of  the  lower  portion  of  the  esophagus.  It  is  not 
improbable    that    some   of    the   hemorrhages    formerly   attributetl    to 


Pig.  3.S. — W.  J.  Taylor's  Specimen  Showing  Rupture  of  a  Varicose  Gastric  Vein  Near 
the  Cardia.  Note  also  Gastro-jejunostomy  Opening,  and  Pagenstecher  Thread  Hanging 
Loose,    with    Piece  of  Undigested  Vegetable  Fibre  Attached. 


erosions  were  in  reality  due  to  the  rupture  of  varicose  veins.  Preble 
(1900)  collected  sixty  cases  of  fatal  gastro-intestinal  hemorrhage  due 
to  cirrhosis  of  the  liver.  Out  of  these  sixty  cases  the  esophagus  was 
examined  in  forty- two;  and  among  these  there  were  found  esophageal 
varices  in  thirty-five  cases,  or  85  per  cent.  The  source  of  the  hemorrhage, 
Preble  states,  was  recorded  in  19  cases,  occurring  16  times  from  rupture 
or  ulceration  of  esophageal  varices,  twice  from  ulcers  over  gastric  veins 
near  the  cardiac  vein,  and  once  from  an  erosion  near  the  cardia.  He 
thinks  it  probable  that  in  many  of  the  cases  in  which  varices  were  present 
ruptures  had  occurred  which  were  overlooked,  as  they  were  not  tested 
by  injection  with  air  or  fluid.  "The  veins  of  the  cardiac  end  of  the 
stomach  are  part  of  the  portal  system,  while  those  of  the  esophagus 
are  part  of  the  systemic  system.  Here,  as  at  the  lower  end  of  the  intes- 
tinal tract,  the  two  systems  are  connected  by  anastomosing  branches 


96  GASTRIC  ULCER 

which,  as  a  rule,  according  to  Orth  and  Kundrat,  are  too  small  or  too 
few  to  contribute  much  to  the  formation  of  a  collateral  circulation 
when  the  portal  system  is  obstructed.  But  when  this  anastomosis  is 
free,  they  become  an  important  factor,  and  their  dilatation  may  so 
completely  compensate  for  the  veins  obstructed  in  the  liver  that  the 
clinical  course  of  the  cirrhosis  is  altered  and  obscured"  (Preble). 

The  blood  in  the  lower  esophageal  veins  is  returned  to  the  heart 
by  way  of  the  lower  azygos  minor  vein,  as  well  as  through  some  of  the 
bronchial  veins;  and,  as  Preble  points  out,  being  intrathoracic  in 
situation,  they  "feel  the  negative  pressure  of  inspiration,  while  at  the 
same  time  the  pressure  in  the  portal  system  rises  to  fourteen  or  ev'en 
eighteen  millimetres  of  mercury.  In  this  way  the  blood  is  literally 
aspirated  from  the  coronary  into  the  esophageal  veins,  and  leads  to 
their  permanent  dilatation." 

In  patients,  therefore,  where  the  anastomosis  between  the  coronary 
and  the  esophageal  veins  is  free,  cirrhosis  of  the  liver  may  not  be  ac- 
companied by  its  usual  symptoms,  such  as  ascites,  enlargement  of  the 
spleen  and  of  the  subcutaneous  abdominal  veins.  Among  the  patients 
with  cirrhosis  whose  records  were  examined  by  Preble,  in  whom  varices 
were  present  and  caused  hemorrhage,  one-third  died  from  hemorrhage 
without  any  accompanying  sign  of  the  cirrhosis;  in  one-third  hemor- 
rhage was  the  first  symptom,  and  others  followed;  and  in  the  other  third 
the  hemorrhage  was  preceded  by  other  symptoms. 

The  surgeon,  therefore,  should  be  very  cautious  about  undertaking 
operations  on  the  stomach  in  the  case  of  a  patient  who  presents  symp- 
toms merely  of  gastric  hemorrhage,  without  other  evidences  of  ulcer. 
If  the  abdomen  of  a  patient  with  esophageal  varices  due  to  cirrhosis 
of  the  liver  be  opened,  there  will  usually  be  found  an  increased  amount 
of  peritoneal  fluid,  and  palpation  of  the  liver  may  detect  the  true  con- 
dition. Under  such  circumstances,  probably  the  best  course  will  be 
to  suture  the  omentum  to  the  parietal  peritoneum,  in  the  hope  of  re- 
lieving the  esophageal  veins  of  some  of  their  pressure.  Certainly  no 
rehef  can  be  expected  from  a  gastro-cnterostomy.  In  cases  of  post- 
operative hemorrhage  we  believe  with  Dieulafoy  that  the  condition 
is  generally  due  to  a  mild  form  of  sepsis,  and  that  in  fatal  cases  one  or 
more  erosions  or  exulcerations  could  be  found  in  the  gastric  or  intes- 
tinal mucosa. 

A  distinction  between  open  ulcer  of  the  stomach  ami  gastric  car- 
cinoma is  not  usually  difficult;  but  in  certain  cases  of  callous  ulcer  with 
much  thickening  and  many  perigastric  adhesions,  the  diagnosis  is 
often  a  matter  of  considerable  importance  as  well  as  difficulty,  since 


PROGNOSIS  97 

the  question  of  radical  treatment  is  at  once  raised.  The  distinction 
is  discussed  under  the  heading  of  malignant  pyloric  obstruction  (see 
page  263).  The  duration  of  the  disease  is  the  most  important  factor 
in  differentiating  a  simple  ulcer  from  a  cancer;  but  it  must  not  be  for- 
gotten that  while  carcinoma  is  typically  abrupt  in  its  onset,  first  mani- 
festing itself  after  forty  years  of  age,  yet  that  it  may  be  implanted  upon 
ulcer,  and  that  a  patient  with  an  ulcer  of  many  years  duration  may  have 
a  carcinoma  which  has  only  recently  developed,  but  whose  course, 
unchecked,  will  be  quickly  fatal.  The  age  of  the  patient,  moreover, 
is  no  certain  guide  as  to  the  presence  of  cancer.  As  is  well  known,  the 
gastro-intestinal  tract  is  affected  with  malignant  growths  in  younger 
patients  than  is  any  other  region  of  the  body. 

Cholelithiasis  usually  is  sufficiently  distinguished  by  the  location 
of  the  symptoms  and  physical  signs,  as  well  as  by  the  extreme  irreg- 
ularity of  the  attacks  of  gall-stone  colic,  which  bear  no  relation  whatever 
to  the  ingestion  of  food,  and  which  recur  with  no  persistence  after  each 
meal,  as  does  the  pain  due  to  gastric  ulcer.  Moreover,  even  in  the 
intervals  between  the  attacks  of  biliary  coHc,  the  digestion  is  never  in 
perfect  order,  though  actual  distress  may  be  absent.     (See  p.  485.) 

Chronic  appendicitis  may  very  closely  mimic  the  symptoms  of 
gastric  and  duodenal  ulcer,  and  is  in  many  patients  a  coincident  disease, 
the  appendicular  focus  of  infection  being  indeed  not  infrequently  the 
original  cause  of  the  gastric  lesions.  But  patients  with  uncomphcated 
chronic  appendicitis  usually  are  younger  than  those  with  ulcer  of  the 
stomach,  most  of  the  latter  being  over  35  years  of  age.  In  appendicitis 
the  dyspeptic  symptoms  bear  no  relation  to  the  ingestion  of  food,  and 
no  relief  is  obtained  by  eating  or  by  ingestion  of  alkalies.  Usually  one 
or  more  attacks  have  occurred  of  sufficient  severity  to  have  laid  the 
patient  up  in  bed  for  a  week  or  ten  days,  and  in  most  cases  attentive 
physical  examination  will  detect  deep  tenderness  in  the  right  iliac 
fossa.  Patients  with  chronic  appendicitis,  moreover,  do  not  give  the 
history  of  intervals  of  entire  freedom  from  digestive  disturbances 
which  is  so  characteristic  of  gastric  and  duodenal  ulcers  in  their  earlier 
stages ;  and  owing  to  the  adhesions  which  early  form  around  the  appen- 
dix, any  unusual  physical  exertion  is  very  apt  to  cause  a  recrudescence 
of  symptoms  in  cases  of  chronic  appendicitis. 

Chronic  Pancreatitis. — The  diagnosis  of  this  condition  is  considered 
at  p.  67c 

Prognosis  in  Cases  of  Gastric  Ulcer 
The  prognosis  in  cases  of  ulcer  of  the  stomach  may  be  considered 
under   three   headings:  (i)  Untreated;    (2)    Medical   Treatment;    (3) 


98  GASTRIC  ULCER 

Surgical  Treatment.  It  is,  however,  extremely  difficult  to  obtain  any 
accurate  data  as  to  the  percentage  of  deaths  and  permanent  cures  under 
the  first  two  headings;  and  even  with  surgical  treatment  we  must  ac- 
knowledge that  it  is  still  of  too  recent  adoption  for  us  to  draw  definite 
conclusions. 

It  is  not  likely  that  a  patient  with  an  ulcer  which  produces  symptoms 
of  any  severity  will  go  untreated.  But  it  must  be  remembered  that 
many  ulcers  are  latent,  and  first  announce  their  presence  by  copious 
hemorrhage  or  lethal  perforation.  Van  Valzah  and  Nisbet,  as  long  ago 
as  1900,  were  able  to  find  scattered  through  the  literature  fifty-eight 
cases  of  latent  ulcer,  the  first  manifestation  of  which  was  perforation. 

But  there  are  many  patients  in  whom  the  symptoms  of  the  disease 
are  subacute  in  character,  and  persist  for  years,  untreated,  until  finally 
some  acute  complication  occurs,  killing  them,  or  at  least  bringing  them 
very  near  death;  or  if  no  acute  complication  arises,  the  patients  pass 
into  the  class  of  chronic  gastric  ulcer,  with  pyloric  obstruction,  gastric 
dilatation,  or  other  more  serious  affections.  Brinton  gave  the  mortality 
from  all  causes  in  gastric  ulcer  as  50  per  cent.;  Lebert  considered  10 
per  cent,  a  fair  estimate;  while  Robson  and  Moynihan  came  to  the 
reasonable  conclusion  that  under  medical  treatment  the  mortahty  of 
gastric  ulcer  is  at  least  20  per  cent.  This  mortality  they  divide  between 
hemorrhage,  which  kills  5  per  cent.,  and  perforation,  which  kills  at 
least  15  per  cent,  of  patients  with  ulcer  of  the  stomach. 

When,  in  addition  to  these  figures,  we  consider  the  other  compli- 
cations to  which  patients  with  gastric  ulcer  are  prone,  we  begin  to  realize 
what  an  alarmingly  serious  disease  it  is,  and  how  unsatisfactory  medical 
treatment  must  be  in  a  great  many  cases.  Among  other  complications 
to  which  gastric  ulcer  may  give  rise  must  be  considered,  in  addition 
to  perforation  and  hemorrhage,  pyloric  stenosis,  with  its  long  train  of 
maladies  due  to  dilated  stomach;  hourglass  stomach,  and  other  results 
of  adhesions  and  distortions;  the  transition  of  ulcer  into  carcinoma 
(seepage  114);  subphrenic  abscess;  and  even  progressive  pernicious  ane- 
mia, which  is  dwelt  upon  in  particular  by  Hemmeter. 

That  medical  treatment  may  accomplish  much  in  patients  suffer- 
ing from  open  ulcer  no  one  can  deny.  The  immediate  mortahty  of 
the  disease  may  probably  be  reduced  to  10  per  cent,  by  the  best  medical 
treatment.  But  the  treatment  must  be  methodical  and  energetic.  No 
half-hearted  measures  will  sufiice.  As  Van  Valzah  and  Nisbet  say, 
"Expectant  treatment  is  a  great  blunder,  for  simple  ulcer  in  a  vigorous 
adult  has  no  'innate  tendency  to  heal,'  and  the  grave  accidents  which 
are  too  often  the  heralds  of  coming  death  occur  somewhat  regardless  of 


PROGNOSIS  99 

the  age,  the  constitution,  and  the  general  state  of  nutrition.  The 
treatment  must  in  every  case  be  immediate,  methodical,  and  suih- 
ciently  vigorous  to  be  effective.  A  compromise  may  mean  death  or 
irreparable  injury." 

To  consider  at  present  only  the  prognosis  of  open  ulcer  of  the 
stomach,   postponing   that   of   the   callous  or   cicatrizing  variety    to 
another  chapter;  it  seem  to  us  that  a  rational  point  of  view  is  the 
following:  to  adopt  at  first  in  every  case  energetic  medical  treatment. 
Under  this,  the  acute  pain,  the  tenderness,  and  the  recurring  hemor- 
rhages of  open  ulcer  can  almost  invariably  be  checked,  and  in  a  certain 
proportion  of  cases,  smaller  we  believe  than  medical  men  as  a  rule 
admit,  these  patients  will  remain  cured.     Unfortunately  medical  men 
are  not  agreed  on  what  is  the  proper  form  of  non-operative  treatment. 
Many  hold  to  the  classical  treatment  of  rest  in  bed,  and  local  rest  for 
the  stomach  procured  by  nearly  total  abstinence  from  mouth  feeding 
for  at  least  one  week,  while  the  patient's  strength  is  supposed  to  be 
supported  by  nutiient  enemata  (Von  Leube).     Others  of  the  modern 
school,  wUl  be  inclined  to  adopt  the  Lenhartz  method,  of  which  Hort's 
treatment  (1910),  is  an  advanced  example.     This  may  be  summarized 
as  follows:  (i)  For  acute  cases,  with  hemorrhage,  subcutaneous  in- 
jections of  normal  horse  serum,  and  feeding  by  mouth  at  the  very 
earliest  opportunity  with  small  dry  meals,  mainly  of  meat;  (2)  For 
chronic  cases,  full  meat  diet  in  an  appropriate  form  from  the  start, 
with  repeated  oral  doses,  never  on  an  empty  stomach,  of  an  antilytic 
serum    specially    prepared.     The    rationale    of    Hort's    treatment    is 
based  on  the  modern  conception  of  the  gastric  or  duodenal  lesion  as 
merely  a  symptom  of  a  blood  infection,  and  not  as  was  formerly  taught 
a  disease  in  itself.     Hort  claims  that  with  this  understanding  of  the 
affection,  the  absorption  of  adequate  protein  in  suitable  form  cannot 
but  increase  the  resistant  powers  of  the  body  as  a  whole  to  the  unknown 
determining  cause  of  the  disease.     He  points  out,  further,  that  protein 
food  will  utilize  the  e.xtra  amount  of  acidity  in  the  stomach;  and  that 
by  adding  at  the  height  of  digestion  a  serum  with  a  high  antipepsin 
and  antitrypsin  content,  some  of  the  unsatisfied  residue  of  peptic  and 
tryptic  bodies  will  combine   therewith,  and   the  ulcer  thus  be  con- 
siderably   shielded    by    the    diversion   of    these    bodies.     Finally,    he 
claims  that  the  local  action  of  this  serum  on  the  ulcer  will  be  beneficial. 
This  antilytic  serum  (normal  serum  with  the  inhibitory  content  arti- 
ficially raised)  is  on  the  market;  and  the  dose  is  from  30  to  40  cc. 
daily,  in  divided  doses  of  10  cc.  each,  always  with  or  directly  after 
food.     He  claims  there  is  no  danger  of  anaphylaxis  if  the  serum  is 


lOO  GASTRIC  ULCER 

given  by  mouth  only.  Sippy  (1915)  adopts  a  method  of  treatment 
which  has  for  its  object  the  prevention  of  the  corrosive  action  of  the 
gastric  juice  on  the  ulcers.  He  gives  largely  a  milk  diet,  with  frequent 
very  large  doses  of  antacids,  sufhcienth-  large  to  neutralize  the  acidity 
of  the  gastric  juice,  which  is  repeatedly  examined.  No  food  residues 
are  allowed  to  remain  in  the  stomach,  and  thus  there  is  no  excitant 
for  the  flow  of  gastric  juice  during  the  hours  of  sleep  when  antacids 
cannot  be  taken  by  mouth.  The  patient  is  kept  in  bed  for  an  average 
period  of  four  weeks,  and  subsec^uently  continues  the  treatment  in 
modified  form  for  months. 

Statistics  which  were  quoted  at  length  in  the  first  edition  of  this 
book,  and  which  so  far  as  we  can  ascertain  are  still  representative  of 
the  results  of  medical  treatment,  lead  us  to  conclude  that  when  the 
s^tnptoms  of  open  ulcer  are  not  relieved  after  energetic  medical  treat- 
ment lasting  for  several  weeks  —  probably  sL\  weeks  should  be  the 
outside  limit  — ■  or  where  the  disease  recurs  after  being  temporarilj' 
checked,  that  then  some  more  radical  treatment  is  required.  This 
treatment  is  operative.  The  choice  of  operation  does  not  concern  us 
here.  It  will  be  discussed  fully  under  the  head  of  treatment.  What 
we  desire  at  present  to  learn  is  the  immediate  mortality  of  surgical 
treatment,  and  the  proportion  of  ultimate  and  enduring  cures  that  we 
may  expect. 

We  have  seen  above  that  under  medical  treatment  the  immediate 
mortality  is  from  10  to  20  per  cent.  The  mortality  of  untreated 
cases  may  be  estimated  at  from  20  to  50  per  cent.  The  average 
death  rate  for  gastro-enterostomy,  which  is  the  operation  still  most 
frequently  employed  in  these  conditions,  is  as  low  in  the  average  at 
the  present  day  as  5  per  cent.,  and  in  the  hands  of  those  surgeons  who 
do  many  of  these  operations  is  even  lower.  The  following  statistics 
have  all  been  reported  since  the  appearance  of  the  first  edition  of 
this  book  (1909). 


PROGNOSIS  lOI 

Statistics  of  Operations  for  Benign  Diseases  of   the   Stomach  and   Duodenum 


Operator 


Number 

Date  of  Deaths 

operations 


Mortality 
per  cent. 


Bidvvell 

iqi  I 

181 

13 

S-o 

Coffey. 

iq20 

^3i  ' 

10 

4  33 

Deaver'  ... 

1920 

67,3 

3f 

S3 

V.  Eiselsberg 

igi4 

334 

17 

5  ° 

Enderlen . 

1914 

S~ 

4 

7   7 

Finney. 

191S 

200 

12 

6.0 

Galpern.. 

IQII 

170 

6 

3   5 

Kocher... 

I9IO 

43 

0 

0  0 

Krabbel  and  Geinil/, 

I9I4 

168 

7 

41 

Kiimmel 

igi2 

71 

4 

5  6 

Kiittner. 

1911 

,56 

5 

9.0 

Mayo  Clinic 

191S-1919 

3480 

53 

I   52 

Mitchell,  A.  B. 

IQI  I 

110 

3 

2.7 

Monsarrat. 

igi2 

ss 

0 

0.0 

Moynihan 

1920 

835 

12 

1-43 

Sherren. . 

1914 

200 

0 

3-0 

Short... 

1911 

41 

0 

0.0 

References 

Bidwell:  West  London  Med.  Jour.,  igii,  .\vi,  265. 

Deaver:  Records  of  Lankenau  Hospital,  Philadelphia. 

V.  Eiselsberg:  Lancet,  1914,  ii,  296. 

Enderlen:  Faulhaber  and  Redwitz,  Mitth.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1914,  x.xviii, 

150. 
Finney:  Surg.  Gyn.  and  Obst.,  1914,  xviii,  273.     Am.  Jour.  Med.  Sc,  1915,  ii,  469. 
Galpern:  Arch.  f.  klin.  Chir.,  igio-ii,  xciv,  870. 
Kocher:  Deutsch.  Zeitschr.  f.  Chir.,  1912,  cxvi,  183. 

Krabbel  and  Geinitz:  Mitth.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1914,  xxvii,  859. 
Kiimmel:  Deutsch.  med.  Woch.,  1912,  xxxviii,  395. 
Kiittner:  Ther.  d.  Gegenwart,  1911,  liii,  19. 

Mayo  Clinic:  Reports  of  St.  Mary's  Hospital,  Rochester,  Minn.,  1915-1919. 
Mitchell:  Annals  of  Surgery,  1911,  liv,  806. 
Monsarrat:  Liverpool  Med.-Chir.  Jour.,  1913,  Ixii,  364. 
Sherren:  Surg.,  Gyn.,  and  Obst.,  1914,  xix,  564. 
Short:  Bristol  Med.-Chir.  Jour.,  1911,  xxix,  220. 

'  In  the  iirst  edition  of  this  work  there  were  recorded  (up  to  the  year  190S)  91  operations 
of  all  kinds  for  benign  diseases  of  the  stomach  with  8  deaths,  a  mortality  of  8.7  per  cent. 
During  the  years  1908-1920  (Jan.  i)  inclusive  the  senior  author  did  5S2  operations  of  all 
kinds  for  such  diseases,  with  28  deaths,  a  mortality  of  4.81  per  cent.  These  figures  may  be 
seen  in  detail  in  the  accompanying  table.  The  entire  period  (1900-1920)  comprises  673 
operations  for  benign  diseases  of  the  stomach  and  duodenum,  with  36  deaths,  a  mortality  of 
5.3  percent. 


I02 


GASTRIC  ULCEE 


Operations  for  Benhgn  Diseases  of  the  Stomach  and  Dl* odenum 


Lankenau  Hospital  (1909-1920) 
Immediate  Mortality 


Number       Recovered 


Died 


Mortality 
per  cent. 


Posterior  gastroenterostomy  for 

Ulcer,  duodenal 

Ulcer,  duodenal,  petf  orated ... . 

Ulcer,  gastric 

Ulcer,  gastric,  perforated. . . 

Ulcer,  pyloric 

Ulcer,  marginal .*.  .  . 

Stenosis,  duodenal. . .' 

Stenosis,  pyloric ,  . 

Adhesions,  pyloric 

Obstruction,  pyloric.  - 

Total 

Partial  gastrectomy  for 

Ulcer,  duodenal 

Ulcer,  duodenal  and  gastric 
Ulcer,  duodenal,  perforated 

Ulcer,  gastric 

Obstruction,  pyloric 


Total 

Pylorectomy  for 

Ulcer,  duodenal , 

Uicer,  duodenal,  perforated 

Ulcer,  gastric 

Fistula,  duodenal 


Total 

Excision 

Ulcer,  duodenal 
Ulcer,  gastric. ... 

Total 

Resection,  circular,  stomach 

Ulcer,  gastric 

Jejunojejunostomy 

Obstruction,  duodenal 
Duodenoduodenostoniy 

Vicious  circle 

Enteroenterostomy 

Adhesions,  abdominal 

Roux-Y  for 

Vicious  circle 

Ulcer,  marginal 

Total 

Anterior  gastroenterostomy 

Ulcer,  marginal 

Gastrostomy  for 

Stricture,  esophagus.  .  . 

Ulcer,  marginal 


Total 

Gastrotomy  for 

Gastritis 

Gastritis,  hemorrhagic 

Gastric  neuroses 

Gastric  linitis 

Foreign  body 


Total 

Gastrorrhaphy 

Ulcer,  gastric,  perforated. .  . 
Duodenorrhaphy 

Ulcer,  duodenal,  perforated. 
Dilatation 

Esophagus 

Gastropli  cation 

Gastrectasis 

Exploratory  for 

Py  lorospasm 

Volvulus 

Esophageal  varices 

Gastric  neuroses 

Cyst,  abdominal 

Hematoma,  abdominal 


Total 

GRAND  TOTAL. 


3 

3 

3 

3 

357 

339 

6 

6 

I 

I 

4 

4 

25 

22 

2 

- 

38 

35 

57 

54 

3.8 


60 

57 

3 

4.6 

49 

48 

I 

22 

22 

0 

71 

70 

I 

I  .4 

16 

15 

I 

6.0 

I 

I 

I 

I 

5S2 


4.81 


PROGNOSIS  103 

Although  the  statistics  from  general  hospitals  are  by  no  means  so 
good  as  those  obtained  by  individual  surgeons,  yet  they  are  bound  to 
improve  as  the  average  surgeon  becomes  more  skillful  both  in  selecting 
his  cases  for  operation,  as  well  as  in  the  actual  performance  of  the  op- 
eration itself.  The  figures  of  some  surgeons  show  an  almost  vanishing 
mortality :  in  the  above  lists  are  several  large  series  of  consecutive  opera- 
tions without  a  single  death.  It  must  be  remembered,  moreover, 
that  these  figures  include  not  only  operations  done  on  stomachs  com- 
paratively slightly  diseased,  but  also  many  operations  done  on 
stomachs  very  extensively  diseased — dilated,  distorted  or  contracted — 
by  chronic  ulceration;  that  the  resistance  of  such  patients  may  be 
expected  to  be  less  that  that  of  the  class  we  are  now  considering,  and 
the  operative  mortality  is  constantly  lessening  as  surgeons  become 
more  expert  and  as  their  experience  increases.  This  progressive  im- 
provement is  well  shown  in  the  figures  published  by  Hartmann  d  905) 
with  characteristic  courage:  His  first  series  of  operations,  done  while 
he  was  assistant  to  Terrier,  comprised  21  gastroenterostomies,  with  5 
deaths,  a  mortality  of  23.7  per  cent.,  a  death  rate  which  is  not  much 
higher  than  that  of  the  average  general  hospital  at  the  present  day. 
Hartmann's  second  series  of  operations,  embracing  those  done  from 
the  time  he  ceased  to  be  assistant  to  Terrier  until  Jan.  i,  1903,  consisted 
of  34  gastroenterostomies,  with  3  deaths,  a  mortahty  of  8.8  per  cent.; 
while  a  later  series,  running  from  1903  to  1905,  including  47  gastroen- 
terostomies, with  only  3  deaths,  showed  a  mortality  of  6.3  per  cent. 
If,  then,  to  these  factors  of  improvement  in  the  surgical  treatment 
itself,  we  add  that  important  one  of  resort  to  surgical  treatment  before 
the  patient  has  become  a  physical  wreck,  the  contrast  between  the 
success  of  surgical  and  the  ultimate  failure  of  medical  treatment 
becomes  even  more  marked.  Hartmann  gives  the  following  interest- 
ing figures,  which  for  the  credit  of  physicians  are  not,  we  are  happy  to 
say,  very  recent.  In  cases  of  gastric  disease  seen  and  treated  primarily 
by  himself  and  his  colleagues — surgeons — the  mortahty  of  operation 
was  two  per  cent.;  but  in  a  series  of  cases  which  had  been  primarily 
treated  medically,  and  which  were  later  referred  to  Hartmann  by  their 
physicians,  the  mortality  of  operation  was  24  per  cent.  The 
two  series  of  cases  included  sixty  patients.  Kocher  wrote:  "The 
majority  of  practitioners  do  not  sufficiently  reahze  what  brilliant 
results  are  to  be  obtained  by  operative  means  in  chronic  affections  of 
the  stomach,  commonly  known  as  gastric  catarrh.  Not  only  can  the 
numerous  dangers  of  ulcerating  affections  of  the  stomach,  such  as 
hemorrhage,  perforation,  transition  into  cancer,  be  prevented,  but  the 


I04  GASTRIC  ULCER 

disease  and  its  results  may  be  so  rapidly  and  certainly  cured  that  the 
medical  treatment  of  obstinate  cases  must  be  put  in  the  background. 
.    .    .    .    The  pain  in  the  stomach  disappears  immediately  after  the 

operation.     This  is  the  invariable  rule The  patient  does 

not  require  to  pay  any  further  attention  to  the  nature  of  his  food.  The 
vomiting  disappears.  The  bowels  become  regular.  Repeated  investi- 
gation of  the  gastric  contents  shows  that  there  is  a  progressive  im- 
provement in  the  process  of  digestion;  hj'peracidity  diminishes;  if  too 
little  acid  is  present,  it  becomes  increased,  a  statement  which  is  in 
accord  with  Steudel,  Carle  and  Fantino,  Kausch,  Hartmann,  Soupault, 
and  Mintz."  Such  words  as  these,  from  a  surgeon  such  as  Kocher, 
who  weighed  well  what  he  wrote  and  knew  whereof  he  spoke,  should 
be  instilled  into  the  mind  of  every  medical  man  who  has  cases  of 
chronic  gastric  indigestion  under  his  care. 

If  the  immediate  results  of  surgical  treatment  are  such  as  have  been 
described,  what  are  the  ultimate  results?  Is  this  condition  of  improve- 
ment maintained?  Are  the  cures  permanent?  A  decision  in  figures 
in  this  instance  is  not  so  easily  reached.  This  is  true  not  only  because 
of  the  difficulty,  which  always  exists,  of  tracing  hospital  patients  after 
operation;  but  also  because  it  has  become  apparent  within  the  last 
few  years  that  only  ulcers  at  or  near  the  pylorus  are  improved  with  any 
constancy  by  means  of  gastroenterostomy;  other  ulcers  may  be  im- 
proved at  least  for  a  time  but  usually  are  not  permanently  or  markedly 
benefited.  Thus  it  is  that  in  massed  statistics,  including  operations 
for  all  varieties  of  benign  diseases  of  the  stomach,  the  ultimate  results 
do  not  appear  to  be  quite  so  excellent  as  earlier  reports  indicated. 
For  exampk.  Bourne  reports  the  end  results  of  gastroenterostomy  in 
68  patients;  of  the  whole  number,  only  51  per  cent,  were  cured.  But 
of  the  pyloric  and  duodenal  ulcers  70  per  cent,  were  cured,  while  of  the 
ulcers  in  the  body  of  the  stomach  only  38  per  cent,  were  cured.  Now 
before  operations  on  the  stomach  were  done  with  any  great  frequency 
only  the  patients  sufiering  with  more  or  less  obstruction  of  the  pylorus 
were  subjected  to  gastroenterostomy;  and  it  is  precisely  this  class  of 
patients  who  derive  most  marked  relief  from  this  operation.  In 
recent  j'ears,  however,  this  operation  has  been  extended  also  to  classes 
of  patients  who.  though  they  may  be  improved  by  it,  certainly  do  not 
show  such  marked  and  rapid  cures  as  are  seen  in  patients  with  pyloric 
stenosis.  The  result  is.  that  in  comprehensive  statistics  the  end- 
results  of  operation  sometimes  seem  to  be  less  satisfactory  than  was 
the  case  five  or  six  years  ago.  The  figures  of  the  senior  author's 
patients  fortunately  exhibit  a  progressive  increase  in  the  proportion  of 


PROGNOSIS 


105 


cases  cured.     These  patients  have  all  been  traced  for  a  year  or  more 
after  operation. 

In  the  following  Table  we  have  assembled  recent  statistics  bearing 
on  this  point.  Unfortunately  most  surgeons  do  not  classify  separately 
their  results  in  cases  of  pyloric  and  those  in  cases  of  non-pyloric  ulcer.^ 

Emd  Results  of  Operations  for  Bexign  Diseases  of  the  Stomach 


Operator 


Bamberger  . 

Bidwell 

Bourne.    . . 

Calderara 

Deaver 

Deaver 

Deaver 

V.  Eiselsberg 

Finney 

Galpern 

Graham  (Mayo  Clinic) 

Gray 

Kocher 

Krabbel  and  Geinitz 

Kummel 

May 

Scrimger,  Archibald  and  Pirie 

Sherren 

Short 

Turner 


Date        Cases  traced 


Webb 


Cured  and 
much  impr. 


Per  cent. 


81 

64.2 

3S 

62.  s 

35 

51-4 

64 

64.0 

49 

76.5 

26 

83.8 

197 

87.9 

176 

71.0 

134 

88.1 

27 

S6.2 

130 

80.2 

49 

92.4 

33 

76.7 

So 

80.8 

47 

94. 

32 

49.2 

538 

20 
117 


40.4 

86. s 

S7-0 

75-4 

89.0  (male  ) 

48.4  (females) 


References 

Bamberger:  Behandl.  d.  chron.  Magengeschwtire,  Berlin,  1909. 

Bidwell:  West.  London  Med.  Jour.,  1911,  xv,  265 

Bourne:  Brit.  Med.  Jour.,  1913,  i,  438. 

Calderara:  Riv.  Ven.  di  Sc.  Med.,  1911,  liv,  452. 

Deaver:  Records  of  the  Lankenau  Hospital,  Philadelphia. 

V.  Eiselsberg:  Surg.  Gyn.  and  Obst.,  1914,  xi.x,  555. 

Finney:  Surg.,  Gyn  &  Obst.,  1914,  xviii,  273;  Am.  J.  I\Ied.  Sc,  1915,  ii,  ^69. 

Galpern:  Arch.  f.  klin.  Chir.,1910-11,  xciv,  S70. 

Graham:  Boston  M.  and  S.  J.,  1914,  cl.xx,  221. 

Gray:  Lancet,  1913,  i,  718. 

'  Eusterman,  according  to  C.  H.  Mayo  (1914),  has  studied  the  end  results  from  the 
Mayo  Clinic,  and  finds  92  per  cent,  of  the  cases  of  gastric  ulcer  with  obstruction  were 
improved  and  74  per  cent,  of  gastric  ulcers  without  obstruction  were  cured  or  improved  by 
operation. 


Io6  GASTRIC  ULCER 

Kocher:  Deutsch.  Zeit.  f.  Chir.,  1912,  cxvi,  185. 

Krabbel  and  Geinitz:  Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1914,  x.xvii,  859. 

Kiimmel:  Deutsch.  med.  Woch.,  1912,  xxxviii,  395,  446. 

May:  Arch.  Middlesex  Hospital,  1910,  xxi,  45. 

Scrimger,  Archibald  and  Pirie:  Canadian  Med.  Ass.  J.,  1914,  iv,  296. 

Sherren:  Surg.,  Gyn  and  Obst.,  1914,  xix,  564. 

Short:  Bristol  M.  J.,  1911,  xxix,  220 

Turner:  Northumberland  and  Durham  M.  J.,  1912,  xx,  60. 

Webb:  Arch.  Jliddlesex  Hospital,  London,  1914-15,  xxxii,  Clin.  S.  xiv,  10. 

Denechau  (1907)  reported  his  study  of  the  end  results  of  gastro- 
enterostomy for  benign  disease,  in  104  patients,  operated  on  by  different 
surgeons.  He  found  "satisfactory"  results  in  54  per  cent.,  moderately 
good  results  in  38  per  cent.,  and  bad  results  (no  improvement)  in  only 
7  per  cent,  of  these  patients. 

Paterson  traced  (1906)  the  subsequent  history  of  116  patients 
who  had  been  operated  on  by  gastro-enterostomy  at  periods  varying 
from  two  to  nineteen  years.  He  concluded  that  over  85  per  cent,  are 
completely  relieved,  and  7  per  cent,  almost  completely  relieved,  thus 
giving  less  than  7  per  cent,  of  cases  in  which  the  results  were  wholly 
unsatisfactory.  He  found,  moreover,  if  from  this  series  were  excluded 
those  cases  in  which  the  anastomotic  opening  was  small  or  in  which 
some  mechanical  appliance  was  used  to  effect  the  anastomosis,  that  the 
proportion  in  which  the  result  had  been  completely  satisfactory  was  92 
per  cent.  This  is  certainly  a  favorable  showing  compared  to  relapses  in 
50  per  cent,  or  more  of  patients  treated  by  medical  means. 

C.  H.  Mayo  (1920),  basing  his  remarks  on  experience  with  2431 
patients,  of  whom  all  but  108  were  traced,  states  that  after  operation 
for  gastric  ulcer,  the  average  death  rate  during  the  succeeding  four 
years  is  slightly  more  than  three  times  normal;  while  after  operation 
for  duodenal  ulcer  it  is  slightly  less  than  normal. 

We  do  not  wish,  however,  to  be  understood  as  urging  surgical 
intervention  in  every  case  of  gastric  ulcer.  As  has  already  been 
stated,  medical  treatment  always  should  be  tried  first,  and  only  when 
methodical  and  energetic  medical  treatment  has  failed  to  cure  the 
patient,  after  it  has  been  persisted  in  for  a  reasonable  time,  or  when 
several  temporary  cures  have  resulted  in  ultimate  relapses,  only  then, 
we  repeat,  is  surgical  treatment  to  be  considered  in  patients  with 
actively  ulcerating  lesions.  In  ulcers  such  as  these,  it  is  mainly  on 
account  of  the  complication  of  hemorrhage  that  the  surgeon's  advice  is 
sought.  Perforation  is  universally  acknowledged  to  call  for  surgical 
intervention  at  the  earliest  possible  moment.  But  in  regard  to  hemor- 
rhage there  is  still  dispute. 


PROGNOSIS  107 

Prognosis  in  Cases  of  Gastric  Hemorrhage. — As  was  pointed 
out  in  connection  with  the  s\Tnptomatology  of  gastric  ulcer,  there 
are  several  distinct  varieties  or  types  in  which  bleeding  from  gastric 
ulcers  occurs.  The  hemorrhage  may  be  profuse  and  overwhelm- 
ing; in  such  cases  it  has  usually  been  found  to  be  due  to  very  small 
acute  ulcerations.  This  form  of  hemorrhage  is  not  readily  amenable  to 
surgical  treatment,  and  usually  subsides  by  medical  measures,  such  as 
astringents,  absolute  rest,  and  the  local  application  of  ice.  Direct 
transfusion  of  blood  is  a  most  valuable  recent  addition  to  our  treatment 
of  these  cases.  It  should  not  be  postponed  too  long  (see  Case  History, 
p.  81).  Hemorrhages  which  are  frequent  and  slight  in  amount  gradu- 
ally sap  the  vitality,  and,  because  often  undetected,  cause  a  profound 
anemia.  Occult  blood  in  the  feces  may  be  the  only  evidence  of  this 
recurring  bleeding.  For  the  relief  of  bleeding  such  as  this,  medical 
measures  are  of  no  avail.  The  bleeding  persists,  the  patient  loses 
ground,  becomes  wasted,  anemic,  thirsty,  feverish.  The  descent  may 
be  easy,  but  it  is  so  merely  because  it  is  gradual.  It  is  none  the  less 
progressive  and  sure.  What  is  lost  is  not  regained,  and  the  attending 
physician  will  realize,  perhaps  too  late,  that  the  decline  into  which  his 
patient  has  fallen  is  not  only  irremediable  by  medical  measures,  but 
may  even  have  reached  the  stage  where  the  shock  of  an  operation  will 
kill.  Surgery — successful  surgery — cannot  be  done  on  patients  who 
have  no  blood;  and  it  is  the  physician's  duty  to  learn  before  it  is  too  late 
that  only  surgery  can  afford  relief.  Direct  transfusion  of  blood  even 
now  may  bring  back  such  patients  from  the  verge  of  the  grave;  but 
their  attending  physicians  should  not  allow  them  to  descend  so  low. 
It  can  be  said  without  any  hesitancy  whatever,  that  when  such  patients 
are  operated  on  in  good  time  they  are  restored  to  health  and  happiness 
with  a  regularity  of  success  which  is  one  of  the  greatest  triumphs  of 
modern  surgery. 

The  other  form  of  hemorrhage  to  which  patients  with  open  ulcer 
are  liable,  occurs  more  frequently  than  that  just  mentioned,  and  is 
characterized  by  the  intermittent,  and  by  no  means  regular,  occurrence 
of  hematemesis.  The  vomitus  may  at  times  be  only  streaked  with 
blood,  or  there  may  be  an  attack  of  vomiting  of  nearly  pure  blood, 
occurring  once  in  six  weeks  or  two  months,  or  even  less  often.  In 
pronounced  and  recurrent  hemorrhage  the  patient  fails  in  health  so 
rapidly  that  radical  measures  are  as  a  rule  willingly  undertaken;  but 
in  the  less  severe  cases  of  hematemesis  the  strength  may  be  partially 
regained  in  the  intervals,  so  that  the  appearance  of  health  is  maintained 
for  some  time;  and  the  patient,  and  the  physician  as  well,  is  often 


I08  GASTRIC  ULCER 

deluded  into  thinking  that  occasional  vomiting  of  blood,  with  annoying 

though  lather  mild  indigestion  during  the  intervals,  is  less  of  an  evil 

than  would  be  resort  to  a  surgical  operation.     Could  such  persons  know 

the  uniformity  with  which  such  symptoms  are  relieved  by  an  operation 

they  would  be  eager  for  its  adoption. 

Case. — Mrs.  S.  \V.,  aged  37  years,  admitted  to  the  (ierman  Hospital  December  7, 
1905.  In  June,  1905,  this  patient  had  been  treated  in  the  medical  wards  of  the  Ger- 
man Hospital  for  severe  hematemesis,  having  vomited  2000  cc.  of  nearly  pure  blood. 
She  had  also  blood  in  her  stools.  Her  hemoglobin  was  25  per  cent.  She  did  well  under 
medical  treatment,  and  refused  operation  when  she  became  strong  enough  in  our  judg- 
ment to  undergo  one.  She  returned  to  her  home,  and  lived  in  comparative  comfort 
until  December,  1905.  when,  after  feeling  uncomfortable  and  ill  at  ease  for  a  few  days, 
she  suddenly  vomited  1500  cc.  of  bright  blood.  She  was  at  once  brought  to  the  Ger- 
man Hospital,  and  soon  after  admission,  on  December  7th,  she  vomited  2000  cc.  of 
blood.  She  was  nearly  exsanguinated,  but  after  receiving  3500  cc.  of  saline  solution  in- 
travenously, appeared  somewhat  improved.  Her  hemoglobin  was  43  per  cent,  on  Decem- 
ber Sth.  Bj'  the  13th  it  had  fallen  to  31  per  cent.,  in  spite  of  energetic  medical  treatment. 
On  December  i6th,  a  posterior  gastro-jejunostomy  with  no  loop  was  done,  and  the 
patient  stood  the  operation  well.  Two  days  later,  however,  on  December  i8th,  she 
died  of  exhaustion,  with  no  further  bleeding  from  the  stomach. 

Evidently  in  this  patient  the  operation  was  done  too  late  to  be 
of  any  service;  she  might  as  well  have  died  without  an  operation.  For 
as  has  already  been  remarked  successful  surgery  cannot  be  done  on 
patients  who  have  no  blood,  and  the  case  of  this  patient  is  a  striking 
example  of  the  truth  of  this  statement,  and  teaches  a  useful  lesson. 

The  prognosis  in  cases  of  gastric  perforation  depends  almost 
entirely  on  the  promptness  and  efficiency  with  which  operative  treat- 
ment is  undertaken.  The  results  of  operation  for  this  condition  will 
be  fully  discussed  under  the  subject  of  treatment  (page  120),  and  it 
remains  at  the  present  time  only  to  say  a  few  words  in  reference  to 
certain  other  circumstances  which  are  held  to  bear  some  relation  to  the 
prognosis.  C.  Brunner  (1903)  laid  stress  on  the  influence  exerted  on 
the  prognosis  by  the  amount  of  hydrochloric  acid  in  the  stomach  at  the 
moment  of  perforation.  The  prognosis,  he  found,  is  most  favorable 
when  the  hj^drochloric  acid  is  most  abundant,  that  is  from  one  to  one 
and  a  half  hours  after  meals;  since  under  these  circumstances  the  gastric 
contents  are  less  septic  than  immediately  (one-quarter  to  one-half  an 
hour)  after  meals,  at  which  period  of  digestion  the  amount  of  hydro- 
chloric acid  in  the  stomach  is  extremely  slight,  and  peritonitis  therefore 
more  likely.  Of  course  perforation  of  an  empty  and  nearly  sterile 
stomach  is  so  much  the  less  dangerous.  The  very  great  fatality  which 
attends  perforation  in  cases  of  gastric  cancer  is  probablx'  owing  to  the 
septic  nature  of  the  stomach  contents  due  to  the  absence  of  hydrochloric 
acid. 


treatment  of  gastric  ulcer  109 

Treatment 

Having,  in  the  previous  paragraphs,  attempted  to  show  which 
cases  of  gastric  ulcer  should,  and  which  should  not  be  subjected  to 
operation,  it  now  becomes  our  duty  to  attempt  to  reach  a  decision  as 
to  what  special  form  of  operation  is  to  be  employed  for  the  relief  of  the 
conditions  already  described.  The  technical  details  of  the  operations 
discussed  will  be  found  described  in  Chapter  XIV. 

Under  the  general  term  gastro-enterostomy  (an  anastomosis  be- 
tween stomach  and  bowel)  may  be  included  the  operation  of  pyloro- 
plasty and  Finney's  modification  of  the  same,  known  sometimes  by 
the  cumbrous  name  of  gastro-pyloro-duodenostomy,  as  well  as  Kocher's 
lateral  gastro-duodenostomy,  and  the  many  and  various  modifications  of 
gastro-jejimostomy.  Of  these  procedures  there  are  only  two — Finney's 
pyloroplasty,  and  gastro-jejunostomy — which  in  our  opinion  merit 
serious  consideration.  And  inasmuch  as  the  same  operations  are 
employed  in  other  affections  of  the  stomach,  which  will  be  described  in 
subsequent  chapters,  it  will  be  most  convenient  to  dicuss  at  some  length, 
in  the  present  place,  the  various  inherent  advantages  and  disadvantages 
of  these  operations.  Pyloroplasty  as  modified  by  Finney  (1902)  is  really 
an  e.xtension  of  the  Heineke-MikuHcz  operation.  As  Mikulicz  stated 
before  the  Philadelphia  Academy  of  Surgery,  in  1903,  the  usual  illus- 
trations of  pyloroplasty  given  in  the  text-books  do  not  accurately  rep- 
resent the  operation,  as  the  incision  should  be  made  much  longer,  so 
as  to  extend  both  into  the  stomach  and  the  duodenum,  and  on  the  lower 
rather  than  the  anterior  wall  of  the  pylorus,  thus  approaching  very 
closely  to  the  more  elaborate  operation  employed  by  Finney.  The 
theoretical  advantages  of  such  an  operation  are  many.  By  this 
method  the  normal  gastro- intestinal  channel  is  not  altered,  the  ingested 
food  passing  at  once  from  the  stomach  into  the  duodenum,  as  in  the 
natural  state;  the  operation  usually  is  not  diflicult  to  perform,  and  the 
subsequent  development  of  regurgitant  vomiting  is  very  unusual;  it  may 
also  be  admitted  that  the  enlargement  of  the  pyloric  orifice  of  the 
stomach  will  secure  to  the  ulcerated  area  all  the  benefits  which 
are  now  believed  to  result  after  lateral  gastro-jejuiiostomy  from 
the  admixture  with  the  gastric  secretion  of  bile  and  pancreatic 
juice.  In  the  hands  of  most  surgeons,  however,  the  death  rate  of 
Finney's  pyloroplasty  has  been  higher  than  has  been  that  of  gastro- 
jejunostomy; but  in  Finney's  own  hands  the  mortality  has  been  lower: 
in  1914  he  reported  100  pyloroplasties  with  5  deaths;  and  in  191 5  100  gas- 
tro-jejunostomies  with  7  deaths.    The  ultimate  results  in  Finneys'  own 


no  GASTRIC  ULCER 

cases  have  also  been  more  satisfactory  after  pyloroplasty  than  after  gastro- 
jejunostomy: 78  patients  traced  one  year  afterpyloroplasty,  showed  73  or 
93.6  per  cent,  satisfactory  results;  while  among  74  patients  traced  more 
than  one  year  after  gastro-jejunostomy  there  were  61  or  84  per  cent,  satis- 
factory results  (Finney  and  Friedenwald).  Other  surgeons  have  been 
very  slow  to  adopt  Finney's  operation,  being  contented  apparently  with 
the  results  of  gastro-jejunostomy.  Mayo  in  1905  reported  that  among 
58  patients  treated  by  Finney's  method  there  were  only  two  (3.4  per 
cent.)  secondary  operations  required,  these  being  for  chronic  regurgi- 
tation of  bile  into  the  stomach,  through  too  large  an  opening;  a  record 
which  shows  that  not  only  were  his  cases  carefully  selected,  but  that  the 
technical  details  of  the  operation  were  carried  out  with  scrupulous  care.^ 
It  is  needless  to  say  that  it  is  this  very  selection  of  cases  which  is  the  most 
difficult  part  of  surgery.  Finney  writes:  "The  only  contraindications 
to  the  operation  are  inability  to  mobilize  the  duodenum  when  adhesions 
are  too  dense,  and  thickening  and  infiltration  about  the  pylorus  due  to 
hypertrophic  forms  of  ulceration."  The  operation,  he  thinks,  "has 
its  greatest  indication  in  the  relief  of  pyloric  stenosis  due  to  chronic 
ulcers,  situated  at  or  near  the  pylorus,  and  on  either  side  of  it,  or  result- 
ing from  the  cicatricial  contraction  following  the  healing  of  such  ulcers. 
It  is  often,"  he  adds,  ''a  useful  procedure  in  cases  of  hemorrhage  due 
to  gastric  ulcers  on  the  lesser  curvature  or  to  duodenal  ulcers  which 
cannot  be  controlled  medically,  and  which  threaten  the  life  of  the 
patient,  as  well  as  in  the  chronic  dyspepsias  due  to  ulcers  which  have  not 
been  relieved  by  medical  treatment."  He  claims  special  advantages 
for  the  opportunity  which  this  operation  affords  to  excise  accessible 
ulcers  after  direct  inspection  of  the  part  affected. 

In  our  opinion  Finney's  method  of  pyloroplasty  should  be  employed 
only  in  patients  where  perigastric  adhesions  are  absent  and  where 
the  plyorus  is  not  involved  in  cicatricial  tissue.  It  will  be  seen  there- 
fore, that  there  are  very  few  cases  indeed  in  which  we  deem  this  operation 
advisable.  Adhesions  are  Nature's  safeguard,  and  should  be  treated 
with  respect.  In  not  a  few  cases  the  adhesions  are  on  guard  over  a 
threatening  perforation  or  over  one  which  had  perforated  before, 
subacutely  or  chronically.  In  such  cases  injudicious  destruction  of 
adhesions  may  open  up  a  perforation  into  the  stomach  which  it  may 
be  impossible  to  close  by  suture,  and  in  any  event  this  procedure  will 
subject  the  patient  to  the  risk  of  septic  peritonitis  from  the  unexpect- 

'  In  the  first  edition  of  this  book  we  quoted  also  the  results  of  ilr.  Rutherford  Morison's 
operations;  but  we  are  informed  by  Mr.  G.  Gray  Turner  that  these  operations  were  Heineke- 
!Mikulicz  pyloroplasties,  and  not  instances  of  Finney's  operation. 


treatment:  excision  hi 

ed,  and  at  times  undiscovered,  extravasation  of  gastric  contents.  The 
safer  course  is  to  perform  gastro-jejunostomy  in  a  healthy  portion  of  the 
stomach  wall,  and  leave  Nature's  barriers  undisturbed.  The  more 
marked  the  pyloric  stenosis,  the  more  certain  are  the  benefits  to  be 
derived  from  gastro-jejunostomy;  and  where  the  pylorus  is  much 
obstructed  it  is  involved  in  cicatricial  tissue,  and  is  an  extremely 
unsuitable  site  for  direct  incision  and  suture.  Stitches  do  not  hold 
well  in  scar  tissue,  and  scar  tissue  does  not  lend  itself  so  readily  to 
an  anastomotic  operation  as  does  normal  serous  tissue,  both  because 
of  rigidity  and  of  the  lack  of  blood  supply.  Yet  in  cases  in  which 
the  pylorus  is  an  obstructive  factor  without  being  ulcerated  or  the 
seat  of  cicatricial  tissue,  Finney's  operation  may  prove  of  value. 

Gastro-jejunostomy,  on  the  other  hand,  has  been  proved  by  clinical 
experience,  the  true  criterion  of  success,  to  fulfill  most  admirably 
the  indications  in  the  surgical  treatment  of  gastric  ulcer.  The  death- 
rate  immediately  due  to  this  operation  is  extremely  low,  varying  from 
three  to  less  than  one  per  cent,  in  the  hands  of  experienced  operators, 
and  averaging  probably  not  much  over  ten  per  cent,  in  collective 
statistics.  But  it  should  be  well  recognized  that  its  ultimate  results 
are  most  satisfactory  in  cases  of  pyloric  ulcer,  especially  if  there  is 
pyloric  obstruction.  It  is  not  the  best  operation  for  all  ulcers  in  other 
parts  of  the  stomach  (Fig.  36),  but  it  is  undoubtedly,  even  for  these, 
the  least  dangerous  and  the  most  generally  applicable  operation.  If 
the  anastomosis  is  made  in  the  pyloric  portion,  not  in  the  body  of  the 
stomach,  the  anastomotic  opening  will  functionate  even  where  the 
pylorus  is  patulous  (Hartmann,  1914);  and  even  if  the  gastric  contents 
do  not  leave  the  stomach  by  the  new  opening,  but  still  are  discharged 
by  the  pylorus,  the  gastro-jejunostomy  aids  in  healing  the  ulcer  by 
permitting  admixture  of  the  bile  and  pancreatic  juices  with  the  stomach 
contents,  thus  diminishing  hyperacidity. 

There  remains  for  consideration  the  treatment  of  gastric  ulcer  by 
excision.  Originally  advocated  by  Rydygier,  it  is  a  method  which 
quickly  fell  into  disrepute,  owing  to  its  enormous  mortality.  But  it 
was  again  revived  by  a  number  of  surgeons  (Maydl,  Jedlicka,  Ali 
Krogius,  Rodman,  Brechot,  and  others),  chiefly  on  the  ground  that  it 
acted  as  a  preventative  of  carcinomatous  degeneration,  but  also  because 
it  was  claimed  that  excision  of  the  ulcer,  or  even,  if  necessary  of  the 
whole  ulcer  bearing  area  (Rodman,  1900),  obviated  the  occurrence  of 
subsequent  hemorrhage  or  perforation,  calamities  which  are  not  entirely 
unknown  after  subsidence  of  symptoms  procured  by  gastroenterostomy. 
Temoin    (191 7)    speaks   of   gastro-jejunostomy   as   a   mere  makeshift 


112 


GASTRIC  ULCER 


when  gastrectomy  proves  impossible;  and  there  is  much  truth  in  Sher- 
ren's  statement  (1920)  that  gastro-jejunostomy  is  of  value  only  in  the 
case  of  an  ulcer  that  is  unadherent  to  a  neighboring  viscus.  Sherren 
reports  that  he  now  adopts  excision  in  50  per  cent,  of  his  cases;  and 
we  have  found  ourselves  being  gradually  forced  into  the  belief  that  in 


Fig.  36. — Skiagraph  Three  Years  after  Gastro-jejunostomy,  Showing  Ulcer  on  Lesser 
Curvature,  near  Cardia,  still  Unhealed.  Symptoms  not  Relieved.  Small  Indurated 
Area  with  Slight  Crater.  Bismuth  Leaving  Stomach  through  Stoma.  {Lewis  Gregory  Cole, 
in  American  Journal  of  Roentgenology,  Nov.,  191 5-)  ' 

all  cases  the  surgeon's  preference  should  be  for  excision,  and  that 
gastrojejunostomy  should  be  employed  only  where  excision  would  be 
particularly  difficult  or  dangerous.  But  even  at  the  present  day  the 
mortality  of  excision  remains  higher,  being  3  to  10  per  cent.,  instead  of 


treatment;  excision 


I  to  3  per  cent,  in  experienced  hands,  as  it  is  in  the  case  of  gastro- 
jejunostomy. The  immediate  mortality  of  partial  gastrectomy  and 
excision  for  benign  disease  is  shown  in  the  following  table. 

Partial  Gastrectomy  and  Excision  for  Benign  Disease 


Operator 


Mortality 
per  cent. 


Deaver  (1909-1920) 

Mayo  Clinic,  St.  Mary's  Hospital  (1915-1919) 

Moyniham  (1909-1920) 

Rodman  (1910-1915)  (collected  cases) 

Sherren  (1920) 

Temoin  (1917) 


'  The  operations  by  the  senior  author  assembled  above  under  the  general  heading 
'partial  gastrectomy"  may  be  disassembled  into  the  following  subheadings; 


Lankenau  Hospital  (1909-1920) 


Mortality 
per  cent. 


Partial  gastrectomy.  .  .  . 

Pylorectomy 

Cylindrical  gastrectomy 
Excision 


Excision  of  an  isolated  ulcer  is  a  less  severe  operation  than  partial 
gastrectomy,  even  when  combined  with  a  gastro-jejunostomy  as  is 
almost  always  the  case.  But  as  gastric  ulcers  are  often  multiple, 
some  may  be  overlooked,  unless  a  formal  excision  of  the  ulcer-bearing 
area  is  done  (a  typical  partial  gastrectomy) ;  and  it  may  prove  impos- 
sible to  remove  all  the  ulcers  without  doing  a  gastrectomy  of  pro- 
hibitory extent.  Moreover,  even  after  the  excision  of  the  suspected 
ulcer  or  ulcers  fatal  hemorrhage  or  perforation  have  occurred  from 
ulcers  which  were  left  (Billroth,  v.  Eiselsberg,  Mayo  Robson  and  others) , 
Rodman  (1915)  collected  171  instances  of  excision  of  gastric  ulcers, 
with  only  3  deaths,  a  mortality  of  1.75  per  cent.  The  reports  of  St. 
Mary's  Hospital,  Rochester,  Minn.  (1915-1919  inclusive)  tabulate  515 
operations  of  excision  of  gastric  ulcers  (including  the  so-called  cautery 
excision,  p.  116),  with  only  10  deaths,  a  mortality  of  less  than  2  per  cent. 
As  already  noted,  among  71  such  operations  by  the  senior  author 
there  has  been  only  one  death.  Transgastric  excision  of  ulcers  on  the 
posterior  wall  of  the  stomach  may  be  adopted  in  cases  where  the  poste- 
rior wall  cannot  otherwise  be  made  accessible  (see  p.  364).     It  has 


114  GASTRIC  ULCER 

been  commended  b}'  v.  Eiselsberg,  who  reported  12  such  operations 
with  4  deaths;  and  by  KUmmel  who  recorded  18  operations  with  only 
2  deaths.  Kiimmel  traced  9  of  his  patients  and  found  they  were  free 
from  symptoms.  The  operations  of  this  nature  by  the  senior  author 
are  included  under  the  heading  excision  in  the  Table  given  at  p.  113. 

The  matter  of  malignant  degeneration  or  carcinomatous  implanta- 
tion in  gastric  ulcers  will  be  discussed  at  length  in  connection  with  the 
etiology  of  carcinoma;  but  it  seems  fair  to  conclude  that  some  micro- 
scopical errors  may  have  been  made  where  gastric  ulcers  have  been 
said  to  have  presented  evidences  of  incipient  malignancy,  just  as 
clinical  errors  have  been  committed  in  condemning  to  an  early  grave 
patients  with  large  pyloric  tumors  seemingly  characteristic  of  cancer, 
which  tumors  have  gradually  and  quietly  melted  away  after  gastro- 
jejunostomy and  other  palliative  operations.  Such  cases  have  been 
observed  by  Terrier,  Bidwell,  Deaver,  Wallis,  v.  Eiselsberg,  Robson, 
Demoulin  and  Tuffier,  Moynihan,  Pantzer,  Mayo,  and  many  others. 
Deaver's  patient,  operated  on  as  a  last  resort  by  anterior  gastroenteros- 
tomy, for  a  supposedly  cancerous  mass,  was  still  in  excellent  health 
more  than  six  years  after  the  operation.  But  the  fact  that  carcinoma 
may  develop  subsequent  to  gastro-jejunostomj'  for  supposedly  benign 
disease  is  a  fact  that  cannot  be  ignored,  and  is  one  of  the  strongest  argu- 
ments in  favor  of  excision.  Jedlicka  pointed  out  that  of  the  14  patients 
whose  stomachs  were  resected  by  him  between  1891  and  1901  for 
carcinoma,  not  one  was  alive  in  1904,  when  he  wrote;  whereas  of  the 
four  patients  whose  stomachs  were  resected  in  the  same  time  for 
supposedly  benign  disease,  which  was  afterwards  however  found 
by  the  microscope  to  be  malignant,  but  in  an  early  stage — that  of  these 
four  patients,  the  first  was  well  eight  years  after  operation,  the  second 
was  well  four  years  after  operation,  the  third  was  still  too  recent  to 
count;  and  only  one  died  of  recurrence,  and  then  only  after  two  cir- 
cular resections  of  the  stomach. 

In  reported  statistics,  however,  where  no  distinction  is  made  be- 
tween operations  for  gastric  and  for  duodenal  ulcer,  it  must  be  borne 
in  mind  how  rare  is  carcinoma  of  the  duodenum,  and  yet  how  much 
more  numerous  are  gastro-jejunostomies  for  duodenal  than  for  gastric 
ulcer  so  that,  as  Coffey  (1920)  points  out  in  his  own  statistics,  the  sub- 
sequent development  of  one  case  of  carcinoma  of  the  stomach  in  a  series 
of  165  gastro-jejunostomies  implies  really  that  it  occurred  among 
approximately  40  such  operations  for  gastric  ulcer,  the  other  three- 
fourths  of  the  operations  having  been  done  for  duodenal  ulcers. 

The  senior  author  has  seen  during  the  past  20  years  five  cases  in 


treatment:  excision  115 

which  carcinoma  of  the  stomach  developed  after  gastro-jejunostomy: 
in  three  cases  the  original  operation  had  been  done  by  himself,  at  the 
Lankenau  Hospital,  and  in  the  two  other  cases  it  had  been  done  else- 
where.    In  two  of  these  patients,  mentioned  in  our  lirst  edition  (Vol. 
I., p.  119)  death  occurred  at  intervals  of  four  and  two  years  respectively 
after  gastro-jejunostomy  by  the  senior  author,  and  though  the  cause 
of  death  was  not  determined  by  autopsy,  it  was  thought  to  be  carcinoma. 
In  the  case  of  all  three  of  the  patients  seen  since  the  date  of  our  first 
edition  (1909),  recurrence  of  symptoms  occurred  in  less  than  a  year 
after  the  primary  operation  (gastro-jejunostomy),  which  only  in  one 
of  the  three  patients  had  been  done  by  the  senior  author.     In  this 
case  recurrence  of  symptoms  and  re-operation  took  place  so  soon  (about 
four  months)  after  the  first  operation,  that  it  is  practically  certain 
carcinoma  was  present  at  that  time  but  was  not  recognized.     More- 
over, in  three  other  cases  in  which  at  the  first  operation  portions  of 
the  stomach  had  been  removed  (partial  gastrectomy)  for  supposedly 
benign  disease,  and   in  which  the  clinical  diagnosis   was  confirmed 
at  the  time  by  the  pathologist,  the  patients  later  came  back  with 
obvious  gastric  carcinomata :  more  sections  of  the  original  specimens, 
made  by  Dr.  Reiman,  did  reveal  an  early  carcinoma  in  one  of  these 
cases,  but  serial  sections,  fairly  complete,  failed  to  show  any  evidence 
of  carcinoma  in  the  original  specimens  from  the  two  other  patients. 

Carcinoma  Developing  Subsequent  to  Gastro-jejunostomy  for  Supposedly  Benign 

Disease 


Cases  of  gastro-; 
•Author                                 jejunostomy    '      'developed 
traced              carcinoma 

Per  cent. 

1 

Bidwell 56 

Czerny 53 

Deaver  (1920) 271 

V.   Eiselsberg 248 

Krabbel  and  Geinitz 99 

Mayo  Robson 97 

Peck 58 

2 

3 
3 

13 
4 
4 
1 

3-S7 
5.66 

I .  I 

S-2I 
4.04 
4.12 

1-7' 

^In  another  patient  of  Peck's  series,  carcinoma  developed  after  e.xcision  of  benign 
ulcer.  Among  135  supposedly  simple  ulcers  excised  by  Sherren  (1920)  the  microscope 
found  carcinoma  in  6. 

As  Moynihan  (1920)  points  out  the  mortality  from  the  later  de- 
velopment of  carcinoma  in  cases  of  gastro-jejunostomy  for  ulcer  of  the 
stomach  is  as  high  as  the  mortality  of  excision  would  have  been  if 
employed  as  the  original  operation. 


Tl6  GASTRIC  ULCER 

Those  gastric  ulcers  which  we  think  best  suited  for  treatment  by 
excision  are  those  at  some  distance  from  the  pylorus;  for  although  a 
number  of  these  patients  are  often  considerably  benefited  by  gastro- 
jejunostomy, yet  it  has  become  perfectly  evident  that  no  such  gratify- 
ing change  in  their  symptoms  is  produced  as  when  the  ulcer  is  seated 
at  the  pylorus.  We  readily  acknowledge  that  we  adopt  excision,  or 
even  partial  gastrectomy,  in  a  very  much  larger  proportion  of  patients 
than  was  the  case  a  few  years  ago;  and  are  prepared  to  go  so  far  as  to 
say  that  in  cases  of  indurated  ulcer,  no  matter  where  situated,  the 
surgeon's  first  choice  should  be  for  excision  of  some  form:  pylorec- 
tomy,  or  partial  gastrectomy  for  pyloric  ulcers,  wedge-shaped  resec- 
tion or  cylindrical  gastrectomy  for  ulcers  on  the  lesser  curvature. 
and  transgastric  excision  for  ulcers  on  the  posterior  wall,  otherwise 
inaccessible.  But  though  these  methods  of  procedure  should  be  the 
surgeon's  first  choice,  he  should  be  conservative  in  his  selection  of 
cases,  and  should  attempt  excision  only  in  the  absence  of  encumbering 
adhesions,  and  in  patients  not  too  ill  to  withstand  what  often  proves 
to  be  a  somewhat  tedious  operation. 

In  many  cases  where  excision  would  be  difficult  or  impossible,  it 
is  relatively  easy  to  destroy  the  ulcer  by  the  actual  cautery,  according 
to  the  method  of  Balfour  (1914) :  if  an  ulcer  is  situated  along  the  lesser 
curvature,  for  example,  the  gastro-hepatic  omentum  is  carefullj' 
detached  from  the  ulcerated  area,  and  this  area  is  burned  through  with 
the  cautery,  until  the  entire  indurated  area  is  destroyed.  The  resulting 
defect  is  sutured  as  if  it  were  a  perforation,  and  these  sutures  are 
reinforced  by  attaching  over  them  the  gastro-hepatic  omentum. 
Thirty-seven  operations  of  this  kind  were  done  in  191 5  at  the  Mayo 
Clinic,  where  the  method  originated,  without  a  death. 

The  question  of  occlusion  of  the  pylorus  as  an  aid  to  gastro-jejunost- 
omy  in  the  cure  of  gastric  ulcers  still  is  unsettled.  It  is  quite  well 
recognized,  as  has  been  stated  already,  that  gastro-jejunostomy  is 
most  efficient  in  the  cure  of  ulcers  situated  at  the  pylorus  and  ac- 
companied by  pyloric  obstruction.  Hence,  apparently,  arose  the 
idea  that  artificial  occlusion  of  the  pylorus  would  be  an  aid  to  gastro- 
jejunostomy in  healing  ulcers  situated  in  other  parts  of  the  stomach, 
and  unattended  by  pyloric  stenosis.  Various  methods  of  occluding 
the  pylorus  have  been  employed,  but  experience  has  shown  that  none 
of  them  except  formal  section  and  closure  of  both  ends  (so-called  "ex- 
clusion of  the  pylorus,"  first  employed  in  1895  ''y  ^°^  Eiselsberg)  is 
permanent  in  its  effects.  The  simplest  method  is  to  infold  the  anterior 
wall  of  the  pyloric  canal  by  a  series  of  sutures  so  as  to  plicate  it  longi- 


treatment:  occlusion  of  pyloktjs  117 

tudinally  (Kelling,  Mayo,  1900).  When  adhesions  are  few  a  purse 
string  of  linen  may  be  passed  completely  around  the  pylorus,  and  drawn 
tight  enough  to  occlude  the  channel;  if  it  is  not  drawn  tight  enough 
the  channel  of  course  will  not  be  occluded  even  temporarily,  and  if  it 
is  drawn  too  tight  the  ligature  will  soon  ulcerate  its  way  into  the 
lumen  of  the  bowel  with  restoration  of  the  natural  channel.  The  same 
uncertainty  applies  to  the  aluminum  bands  suggested  by  Brewer  (1914). 
Other  surgeons  have  incised  all  the  coats  but  the  mucous,  have  sepa- 
rated this  as  a  tube  without  opening  the  lumen  of  the  pylorus,  and  have 
finally  Hgated  this  mucous  tube  and  closed  over  it  the  muscular  and 
serous  coats.  Others  again  have  gone  one  step  further  in  a  similar 
operation,  and  have  ligated  this  mucous  tube  in  two  places,  dividing 
the  mucosa  between  the  ligatures,  thinking  thus  to  make  a  permanent 
occlusion  of  the  pylorus  (Biondi,  Lewisohn).  Still  others  (Wilms, 
Hoffman,  Strauss,  Polya,  Bircher)  have  employed  a  free  transplant  of 
fascia  (fascia  lata,  sheath  of  rectus,  abdominis,  round  ligament  of 
liver,  etc.)  to  ligate  the  pylorus,  either  without  incising  its  walls, 
or  after  dissecting  the  mucous  coat  as  a  tube  after  incising  the  serous 
and  muscular  tunics.  But  clinical  and  experimental  observations  have 
made  it  fairly  certain  that  none  of  these  methods,  except  v.  Eiselsberg's, 
maintains  occlusion  for  more  than  a  few  weeks  on  the  average.  Many 
surgeons  are  contented  with  this,  and  contend  that  this  is  quite  long 
enough,  as  all  the  benefits  derived  from  pyloric  occlusion  are  to  be 
anticipated  in  the  time  immediately  following  operation,  and  assert 
that  permanent  occlusion  is  not  to  be  desired.  In  our  own  mind  it 
remains  extremely  doubtful  whether  temporary  occlusion  of  the 
pylorus  is  of  any  value  as  a  primary  operation.  In  cases  of  "vicious, 
circle"  following  gastro-jejunostomy,  which  fortunately  are  very 
rarely  seen  at  the  present  time,  we  have  employed  ligation  of  the 
pylorus  a  number  of  times,  and  have  reason  to  believe  that  it  was  the 
cause  of  relief  of  symptoms.  The  only  theory  on  which  pyloric  occlu- 
sion can  be  held  to  be  of  value  as  a  primary  operation  is  that  which 
teaches  that  gastro-enterostomy  is  of  benefit  not  by  admitting  to  the 
stomach  an  excess  of  alkaline  duodenal  secretions  (the  theory  which 
heretofore  has  had  most  to  support  it)  but  merely  by  accelerating  the 
evacuation  of  the  stomach,  and  thus  lessening  the  time  during  which 
peptic  corrosion  of  the  ulcers  can  take  place.  Sippy  (191 5)  holds  the 
latter  view;  he  teaches  that  as  pepsin  acts  only  in  an  acid  medium,  and 
as  the  acidity  of  the  gastric  juice  depends  very  largely  on  the  presence 
of  food  in  the  stomach,  the  only  good  gastro-enterostomy  can  do  is  to 
accelerate  the  evacuation  of  food  from  the  stomach;  so  long  as  the  pylor- 


Il8  '  GASTRIC  ULCER 

US  is  even  partly  open,  he  argues,  little  or  no  gastric  contents  will 
pass  by  way  of  the  anastomotic  opening,  and  it  is  therefore  of  little 
value;  but  if  the  pylorus  is  occluded  (by  stenosis  from  ulceration,  or 
by  ligation,  plication,  etc.)  then  the  anastomotic  opening  serves  for 
evacuating  the  stomach,  and  accomplishes  this  in  less  than  the  normal 
time.  He  overlooks  the  fact,  we  believe,  that  in  duodenal  ulcer  the 
stomach  is  often  emptied  through  the  pylorus  in  less  than  the  normal 
time  and  yet  that  the  addition  of  a  gastro-jejunostomy  promotes 
healing  of  the  ulcer  without  further  accelerating  the  speed  of  evacu- 
ation; the  only  reasonable  conclusion  it  seems  to  us  is  that  the  benefit 
of  gastro-enterostomy  is  due  to  the  increased  alkalinity  of  the  gastric 
contents  secured  b}-  admission  to  the  stomach  through  the  anasto- 
motic opening  of  the  alkaline  duodenal  juices.  INIoreover,  an  anasto- 
motic opening  properly  placed  (in  the  pyloric  portion)  functionates 
even  in  the  presence  of  an  open  pylorus,  as  shown  by  Hartmann  (1914). 
Therefore  it  remains  doubtful  whether  primary  occlusion  of  the  pylorus 
is  of  any  value. 

Sherren  (1920),  who  says  he  has  never  done  an  exclusion  of  the 
pylorus,  has  had  eight  autopsies  from  2  to  9  years  after  operation 
(gastro-jejunostomjO  for  gastric  ulcer,  and  in  all  cases  the  ulcer  had 
healed  perfectly;  moreover  in  13  patients  he  saw  the  stomach  at  sub- 
sequent operations  from  2  weeks  to  7  3"ears  after  the  primary  opera- 
tion; and  in  every  case  the  ulcer  had  healed. 

In  stomachs  e.xtensively  contracted  from  chronic  ulceration, 
V.  Eiselsberg  (1897)  advocated  the  palliative  operation  of  jejunostomy. 
Duodenostomy,  above  the  bile  papilla,  has  been  urged  by  Hartmann 
(1903)  as  a  better  operation.  Bullitt's  patient  (1907)  was  in  fair 
health  ten  months  after  operation.  R.  S.  Fowler  (1916)  reports  a  case 
of  jejunostomy  for  extensive  callous  ulceration  involving  most  of  the 
greater  curvature  of  the  stomach,  which  had  brought  the  patient  to 
death's  door;  relief  was  immediate,  the  tube  being  worn  for  six  months, 
and  the  patient  then  reporting  in  normal  health,  which  was  maintained 
at  the  last  report  about  three  years  after  operation.  Patients  such 
as  these,  in  whom  no  operation  of  any  magnitude  can  be  employed, 
are  often  relieved  at  least  temporarily  by  jejunostomy;  and  though 
it  is  probable  that  most  cases  have  not  the  happy  terminations  noted  in 
most  of  the  published  instances,  nevertheless,  if  it  is  possible  to  lessen 
the  discomforts  of  the  patients  for  a  few  weeks  before  death,  the 
surgeon  need  not  hesitate  to  resort  to  this  now  classical  palliative 
operation.     (See  also  p.  273.) 

In  regard  to  the  treatment  of  hemorrhage,  probably  enough  has  been 


TREATMENT   OF   HEMORRHAGE  II9 

said  in  the  section  on  prognosis,  where  it  was  pointed  out  that  surgical 
intervention  is  most  successful  where  operation  can  be  done  between 
attacks  of  hematemesis;  and  that  operations  done  with  any  idea  of 
locating  and  ligating  the  bleeding  point,  in  cases  of  acute  hemorrhage, 
fail  in  the  immense  majority  of  instances  to  accomplish  the  desired 
result.  Yet  Dieulafoy  urged  operation  in  these  very  cases  "at  the 
opportune  moment."  In  the  sudden,  profuse,  and  overwhelming 
bleeding  sometimes  encountered,  and  which  is  generally  the  first  and 
sometimes  the  only  symptom  of  the  "exulceratio  simplex"  known  by 
his  name  (see  p.  70),  he  strongly  counseled  surgical  intervention  on 
the  first  recurrence  of  the  bleeding.  The  first  patient  whom  he  saw 
with  this  variety  of  hemorrhage  died  from  recurrence  of  the  profuse 
hematemesis  shortly  after  coming  under  observation.  At  autopsy 
the  seat  of  hemorrhage  was  found  in  a  small  arteriole  just  beneath  the 
muscularis  mucosae,  which  has  been  perforated  by  an  "exulceratio  sim- 
plex." In  his  second  patient  he  correctly  diagnosed  the  cause  of  the 
hemorrhage,  and  on  its  recurrence  the  next  morning  induced  Cazin  to 
operate  in  the  hope  of  finding  and  ligating  the  bleeding  point.  The 
stomach  was  opened  and  by  everting  its  mucous  lining  through  the 
incision  like  a  glove  on  the  hand,  and  by  minutely  searching  among 
the  mucous  folds  and  rugae,  a  suspicious  looking  area  was  detected. 
The  manipulation  and  sponging  of  this  area  started  the  bleeding  afresh 
and  the  arteriole  was  then  ligated,  the  patient  making  a  good  recovery. 
Robson  and  Moynihan  in  1904  recorded  two  similar  cases  in  which 
several  bleeding  points  were  successfully  ligated.  We  should  feel 
extremely  loath  to  undertake  an  operation  in  cases  such  as  these,  where 
the  chance  of  discovering  the  seat  of  hemorrhage  is  so  exceptionally 
slight,  and  where  medical  treatment  offers  a  probability  of  cure  in  a 
fair  proportion  of  cases. 

The  alarming  mortality  which  attends  operations  undertaken 
for  the  relief  of  acute  hemorrhage  may  be  seen  from  the  following 
figures  quoted  from  Lieblein  and  Hilgenreiner  (1905) :  Hartmann 
reported  a  mortality  of  63  per  cent.;  Savariaud,  66  per  cent.;  Robson 
(42  cases),  64  per  cent.;  Quenu,  45  per  cent.;  Kaupe,  40  per  cent, 
(probably  mostly  chronic  recurring  bleeding).  Munro  (1904)  out  of  a 
series  of  eight  patients  operated  on  for  acute  hemorrhage  saved  only 
one.  Moynihan's  mortality  among  27  operations  was  nearly  26  per 
cent.  Tuffier  says  that  with  medical  treatment  the  mortality  from 
acute  gastric  hemorrhage  is  only  1.7  per  cent.,  so  that  even  if  some  cases 
included  under  medical  treatment  were  so  mild  as  never  to  have  been 
considered  surgical,  and  even  if  we  accept  the  highest  mortality  under 


I20 


GASTRIC  ULCER 


medical  treatment,  that  of  ii  per  cent.,  given  by  Miiller,  yet  the 
difference  in  the  mortality  between  medical  and  surgical  treatment 
is  too  great  for  surgical  treatment  to  be  preferred  in  patients  with 
acute  hemorrhage,  save  in  the  most  exceptional  cases.  Direct  trans- 
fusion of  blood  usually  will  not  only  promptly  check  the  bleeding,  but 
will  in  most  cases  render  even  an  extremely  anemic  patient  a  lit  sub- 
ject for  operation.  Rodman  (1915)  advocated  the  use  of  water  at  a 
temperature  of  130  degrees  through  the  stomach  tube;  he  said  in  20 
such  cases  of  gastric  hemorrhage  this  treatment  had  never  failed  to 
check  the  bleeding. 

Nor  in  recurrent  hemorrhage,  when  the  operation  is  done  in  the 
interval,  is  it  desirable  to  ligate  or  excise  the  offending  ulcer,  unless 
this  is  callous  and  indurated,  and  then  only  when  it  is  easily  accessible. 
It  usually  suffices  to  infold  the  gastric  walls  over  the  ulcer,  catching  in 
the  sutures  any  vessels  which  seem  to  lead  up  to  the  ulcer;  this  should 
of  course  be  supplemented  by  gastro-jejunostomy. 

The  treatment  of  perforation  of  a  gastric  ulcer,  is  unquestionably 
operative.  Without  operation  death  will  be  the  natural  consequence 
in  99  per  cent,  of  cases.  Suture  of  a  gastric  perforation  was  first  done 
by  Mikulicz  in  1889,  but  without  success.  The  first  instance  of  re- 
covery after  suture  of  a  gastric  perforation  was  recorded  in  1892  by 
Kriege.  From  statistics  given  in  the  first  edition  of  this  work  it  is 
evident  that  in  the  usual  run  of  cases  it  was  at  that  time  (1909)  ex- 
ceptional for  more  than  half  of  these  patients  to  be  saved  by  operation. 
We  give  below  in  tabulated  form,  statistics  which  have  been  published 
since  the  first  edition  of  this  book  appeared. 

* 
Results  op  Operations  for  Gastric  and  Duodenal    Perforations   (Collective 

Statistics) 


Operator 


Cases 


Died 


I  Mortality 
per  cent. 


Caird  (Edinb.  Med.  Jour.,  1914,  xiii,  455) 

1896-1903 

1904-1913 

Hartmann  and  Lecene  (Annals of  Surg.,  1914,  Ix,  227) 

Peck  (Jour.  Am.  Med.  Ass.,  1915,  Ixv,  659) 

Petren  (1894-1910)  (Surg.  Gyn.  and  Obst.,  1912,  xiv,  544). 

Scully  (Am.  J.  Med.  Sc,  1918,  civ,  S74) 

Short  (Bristol  Med.  Chir.  J.,  1911,  xxix,  220) 

Walker  (Bost.  M.  &  S.  J.,  19x5,  clxxiii,  452) 

Wetterstand  (1900-19x0)  (Deutsch.  Zeit.  £.  Chir.,  X913,  cxxi, 
393) 


S4 

34 

193 

71 

202 

107 

30 

8 

13s 

81 

49 

28 

58 

26 

78 

21 

60 

33 

63 
36 

26 
60, 

57. 
44- 
26. 


55 -5 


TREATMENT  OF  PERFORATION  121 

It  seems  from  these  figures  that  the  death  rate  of  this  complication 
is  still  needlessly  high.  If  all  patients  were  operated  on  at  the  most 
opportune  time,  that  is,  within  a  few  hours  of  perforation,  the  results 
would  be  much  better,  as  may  be  seen  in  the  accompanying  table, 
taken  from  the  monograph  of  Gross  and  Gross  (1904)  and  from  that 
of  F.  Brunner  (1903).  In  237  instances  noted  by  Gross  and  Gross  the 
time  between  perforation  and  operation  was  recorded ;  and  the  results, 
as  well  as  Brunner's  figures  may  be  thus  presented: 


Duration  of  perforation 


Mortality  per  cent. 


Gross  and  Gross 


Brunner 


Less  than  12  hours. . 
Less  than  24  hours. . 
Less  than  48  hours. . 
More  than  48  hours 


25.00 

25 

52-7^ 

46 

56.06 

58 

7391 

80 

If  the  results  of  individual  surgeons  are  examined  it  will  be  seen 
that  the  personal  equation  has  something  to  do  with  the  results.  Thus 
a  surgeon  who  has  seen  a  number  of  these  patients  will  not  only  make 
his  diagnosis  more  quickly,^  and  will  hence  operate  sooner,  but  the 
operation  itself  will  probably  be  performed  with  greater  skill  and 
dispatch  than  will  one  done  by  the  occasional  operator.  The  same 
will  be  true  of  a  series  of  operations  done  in  a  well-equipped  hospital, 
by  various  members  of  the  same  staff. ^  The  following  figures  accord- 
ingly are  not  without  their  interest: 

'  In  most  metropolitan  hospitals  the  Internes  on  duty  in  the  Receiving  Ward  rarely  fail 
to  make  the  correct  diagnosis. 

'  Of  57  operations  for  perforations,  done  by  the  Senior  Author,  42  were  for  duo- 
denal and  only  15  for  gastric  perforations.  A  primary  gastro-jejunostomy  was  done  in 
44  cases,  there  being  3  deaths  in  this  series,  a  mortality  of  6.8  per  cent.;  suture  alone 
was  done  in  8  cases,  with  one  death  (12.5  per  cent.);  and  partial  gastrectomy  was 
done  in  5  cases,  without  a  death. 


122 


GASTRIC  ULCER 


Results  of  Operatioxs  by  Individual  Surgeons  for  Gastric  and  Duodenal  Per. 

forations 


Operator 


Mortality 


10' 

3» 
2 

30.0 
16.6 

Alexander  (Episcopal  Hospital,  Phila) 

12 

Collinson  (Jour.  Am.  Med.  Assoc,  1914,  Ixiii,  1184)  .... 

53 

20 

37-7 

Connors  (Amer.  J.  Surg.,  1916,  xx.x,  173) 

42 

14 

33-3 

Deaver  (German  Hospital,  Phila.,  to  Jan  i,  1920) 

bi' 

4 

6.34 

Deaver,  H.  C.  (Episcopal  Hospital  to  June  30.  1920).. 

16 

2 

12.5 

Farr  (Annals  of  Surg.,  1920.  ii,  591) 

-B 

3 

12.0 

Gibson  (Surg.,  Gyn.  and  Obst.,  I9i6,xxii,  388) 

14 

I 

7-1 

Kirk  (Choyce's  System  of  Surg.,  1912, 11,356) 

11 

0 

0.0 

Mayo  Clinic  (St.  Mary's  Hospital  Reports,  Rochester, 

Minn.,  igii-1915.) 

27 

S 

18.5 

Moynihan  (Bost.  Med.  J.,  1910,  I,  241.) 

25 

5^ 

20.0 

Miller  (Trans.  Phila.  Acad.  Surg.,  1915,  xvii,  160) 

6 

2 

33-3 

Peck  (Jour.  Am.  Med.  Assoc,  1915,  Ixv,  639.) 

12 

0 

0.0 

Ross  (Trans.  Phila.  Acad.  Surg.,  1915,  xvii,  151) 

6 

2 

33-3 

Rodelius  (Beitr.  z.  klin.  Chir.,  1914,  xcii,  277) 

15 

8 

60.0 

Sherren  (Choyce's  System  of  Surg.,  1912,  ii,  356) 

28 

12* 

42.8 

Struthers  (Edinb.  Med.  J.,    1920,  xxiv,  748) 

90 

20 

22.2 

Sullivan  (Jour.  Am.  Med.  Assoc,  1916,  ii,  330) 

20 

I 

50 

Wagner  (Deutsch,  Zeit.  f.  Chir.,  1912-1913,  cxx,  438) .  .  . 

IS 

6 

40.0 

'  One  successful  operation  by  Dr.  I.  M.  Boykin. 

'  Two  patients  nearly  moribund  at  time  of  operation;  one  aged  84  years. 

'  Two  other  patients  moribund  when  first  seen,  died  without  operation. 

'  Seven  other  patients  died  without  operation.     Notes  of  4  of  these  cases  follow: 

Male,  51  yrs.,  perforation  2  days  before  admission,  admitted  moribund,  death  in 
10  hours.     (March  10,  1911.) 

Male,  57  years,  admitted  with  diffuse  peritonitis,  thought  to  be  from  strangulated 
right  inguinal  hernia.  Drainage  of  abdomen  through  inguinal  canal.  Death  in  2  days. 
(Apiil  IS,  1911.) 

Male,  38  years,  perforation  3  days  before  admission,  admitted  moribund,  death  in 
10  hours.     (Oct.  18,  1911.) 

Male,  32  years,  perforation  14  hours  before  admission,  while  on  alcoholic  debauch; 
admitted  moribund,  and  died  in  5  hours.     (June  3,  1916.) 

The  diagnosis  in  all  these  cases  was  confirmed  by  post-mortem  examination.  If  all 
these  deaths  are  added  to  the  figures  above,  the  mortality  is  15.7  per  cent. 

'  All  the  fatal  cases,  as  well  as  six  of  the  recoveries,  came  to  operation  more  than  24 
hours  after  perforation. 

It  thus  appears  that  at  the  present  time  from  si.xty  to  seventy  per 
cent,  or  more  of  patients  are  being  saved,  and  that  with  prompt 
operation  the  mortaHty  may  be  expected  to  be  as  low  as  ten  or  even 
five  per  cent. 

Gross  and  Gross  also  analyzed  the  results  in  the  series  of  cases 
collected  by  them,  so  as  to  include  operations  done  within  five  hour 


TREATMENT  OF  PERFORATION  1 23 

periods  after   perforation.     Thus   they   found  that  of  those  patients 
operated  on 

within  the  first  five  Iiours 31-03  per  cent.  died. 

Within  the  second  five  liours 16.25  P^"^  cent.  died. 

Within  the  third  five  hours 42  85  per  cent.  died. 

Within  the  fourth  five  hours 54- 00  per  cent.  died. 

Within  the  fifth  five  hours 57-14  per  cent.  died. 

This  seems  to  show  that  operations  undertaken  within  the  first  five 
hours  are  less  successful  than  those  done  during  the  second  period 
of  five  hours;  but  we  think  that  notwithstanding  these  figures  no 
surgeon  should  hesitate  to  open  the  abdomen  at  the  earliest  pos- 
sible moment  after  perforation  has  occurred.  To  postpone  operation 
is  usually  to  await  the  development  of  an  irremediable  peritonitis; 
indeed  some  patients  are  so  profoundly  toxic  that  they  do  not 
survive  long  enough  for  peritoneal  reaction  to  occur.  The  apparent 
contradiction  between  clinical  experience  and  the  figures  obtained 
on  analysis  could  probably  in  this  instance  as  in  others  be  satisfactorily 
explained  if  the  cases  had  been  reported  in  greater  detail;  when  it 
probably  would  have  been  found  that  the  majority  of  those  patients 
operated  on  within  the  first  five  hours  after  perforation,  suffered  from 
severer  lesions  than  did  the  others.  Shock  in  these  patients  is  in  large 
measure  due  to  the  toxemia  due  to  absorption  from  the  suddenly 
inundated  peritoneal  cavity;  and  the  best  method  of  arresting  this  is  to 
open  the  abdomen,  close  the  perforation  and  relieve  the  intra-abdominal 
tension  by  drainage. 

Bearing  on  this  subject  the  observations  of  F.  Brunner  (1903) 
are  of  interest.  He  constructed  curves  to  represent  graphically  the 
prognosis  after  operation  in  cases  of  gastric  perforation.  According 
to  this  method  he  finds  that  the  curve  of  mortaUty  gradually  approaches 
that  of  recovery  up  to  the  eleventh  hour  after  perforation,  when  it 
crosses  the  curve  of  recovery,  and  thereafter  exceeds  it.  The  curve 
of  recovery  before  the  eleventh  hour  is  parallel  with  the  curve  of  ab- 
dominal rigidity;  while  the  curve  of  mortality  after  the  eleventh  hour  is 
parallel  to  the  curve  of  abdominal  distention.  In  other  words,  at  the 
eleventh  hour,  the  chances  of  recovery  are  about  50  per  cent.,  being 
greater  before,  and  growing  progressively  less  after  the  fateful  hour  has 
been  passed.  The  prognosis  also  is  good  so  long  as  the  abdomen  is 
rigid;  but  when  absorption  of  peritonitic  toxins  has  caused  abdominal 
distention,  the  prognosis  becomes  progressively  worse  the  longer  the 
time  that  has  elapsed  since  the  subsidence  of  rigidity.     All  these  ob- 


I  24  GASTRIC  ULCER 

servations  render  the  importance  of  prompt  operation  so  much  the 
more  apparent. 

Most  gastric  perforations  are  on  the  anterior  wall  of  the  stomach 
and  are  fairly  accessible.  Baker  (191 7)  proposed  administering  by 
mouth  to  patients  with  symptoms  of  perforation  a  dose  of  3  grains  of 
methylene  blue,  dissolved  in  an  ounce  of  water.  The  stain,  escaping 
from  the  perforation,  aids  in  its  location.  We  have  had  no  occasion 
to  employ  this  method.  Excision  of  the  ulcer  is  an  unnecessary 
waste  of  time' ;  by  this  procedure,  moreover,  the  surgeon  not  only 
leaves  himself  a  larger  opening  to  close,  but  may  also  add  the  com- 
plication of  hemorrhage  to  that  of  perforation,  since  some  good  sized 
vessels  may  be  divided.  Sero-serous  suture  of  the  perforation,  without 
even  attempting  to  freshen  its  edges,  is  quite  sufficient.  It  is  better  to 
use  linen  than  catgut. 

But  in  certain  instances  it  is  impossible  to  close  the  opening  securely 
by  suture,  and  in  some  rare  cases  the  perforation  will  be  so  situated 
or  its  edges  will  be  so  friable  that  sutures  of  any  kind,  even  insecure 
sutures,  cannot  be  inserted.  Under  such  circumstances  the  surgeon 
should  endeavor  to  close  the  perforation  by  suturing  a  tag  of  the  great 
omentum  over  it,  a  method  which  appears  to  have  been  first  employed 
in  1897  by  Braun.  Or  the  gastro-hepatic  omentum  may  be  anchored 
dowTi  to  the  perforation  if  more  convenient.  In  cases  where  such 
devices  fail,  the  surgeon  should  not  despair  of  curing  his  patient,  but 
should  pack  off  the  perforated  area  with  gauze  pads,  as  is  done  in  similar 
circumstances  in  other  regions  of  the  abdomen.  This  is  a  much  safer 
plan  than  attempting  to  suture  the  perforation  to  the  abdominal  wall. 
F.  B  runner  (1903)  collected  15  cases  of  perforation  of  the  stomach 
treated  by  packing  without  suture.  Of  these  no  less  than  1 2  recovered ; 
whereas  suture  of  the  perforation  to  the  abdominal  wall  is  nearly  always 
followed  by  death.  To  these  cases  of  gastric  perforation  treated 
by  packing,  recorded  by  Brunner,  may  be  added  Wood's  patient  (1904) 
who  also  recovered,  thus  giving  16  recoveries  and  only  3  deaths  for 
this  method  of  treatment,  a  mortality  of  only  18.75  P^"^  cent.  The 
resulting  gastric  fistula  has  closed  spontaneously  almost  without 
exception. 

\"illard  and  Pinatelle  (1904)  strongly  commended  packing  for 
ulcers  which  have  perforated  among  adhesions  close  to  the  lesser  cur\'a- 
ture.  Atter  the  packs  have  been  placed  the  greater  curv^ature  of  the 
stomach  may  be  sutured  to  the  abdominal  wall  if  there  is  doubt  as  to  the 

'  Finney,  however,  strongly  commends  excision  of  pyloric  ulcers  in  the  longitudinal 
axis  of  the  canal,  with  closure  of  the  opening  according  to  his  method  of  pyloroplasty. 


TREATMENT  OF  PERFORATION  I  25 

efficiency  of  the  packs.  These  authors  collected  9  cases  of  this  charac- 
ter, treated  by  packing  without  suture:  all  three  patients  in  whom  the 
perforation  was  drained  by  a  tube  into  the  stomach,  packed  around 
with  gauze,  recovered  from  the  operation;  while  of  the  remaining  six 
patients  in  whom  gauze  packs  alone  were  used,  four  recovered  and  two 
died.  The  two  fatal  cases  were  in  patients  operated  on  respectively 
37  and  60  hours  after  perforation  had  occurred;  the  first  survived  the 
operation  by  six  and  the  second  by  ten  days,  showing  that  they  pos- 
sessed an  unusually  good  chance  of  ultimate  recovery. 

The  abdomen  should  invariably  be  drained.  The  surgeon  should 
studiously  avoid  the  example  of  Young  (1905),  who,  because  he  thought 
it  impossible  to  drain  well,  did  not  drain  at  all.  His  unfortunate 
patient  did  well  for  four  weeks  in  spite  of  the  fact  that  he  had  two  per- 
forations in  his  stomach;  but  finally  succumbed  in  the  fifth  week  to 
exhaustion  due  to  a  large  subphrenic  abscess. 

If  the  closure  of  the  perforation  is  secure,  the  surrounding  tissues 
not  being  friable,  and  the  sutures  holding  well,  the  epigastric  incision 
may  be  closed  without  drainage;  but  in  cases  where  there  is  the  least 
possible  doubt  as  to  the  sutures  holding  it  is  indispensable  to  leave  a 
cigarette  drain  in  the  upper  wound,  /w  all  cases,  whether  the  epigastric 
incision  is  drained  or  not,  a  second  incision  should  be  made  in  the 
suprapubic  region,  and  the  pelvis  should  be  drained  by  a  glass  tube 
as  in  other  cases  of  diffuse  peritonitis.  This  is  imperative,  because, 
although  in  most  cases  in  which  operation  is  done  within  12  hours  of 
perforation  the  peritoneal  exudate  is  sterile,  it  is  not  always  so.  One  of 
us  (Ashhurst)  has  found  the  colon  bacillus  in  mixed  culture  in  the  pelvic 
exudate  within  less  than  5  hours  after  perforation  of  a  duodenal  ulcer, 
though  clinically  there  was  nothing  to  distinguish  this  case  from  others 
in  which  the  exudate  was  sterile. 

No  irrigation  of  the  peritoneal  cavity  should  be  employed.  We 
believe  this  statement  holds  good  even  for  late  cases,  or  for  those 
where  food  particles  may  be  recognized  in  the  exudate.  The  chances  of 
recovery  will  be  greater  in  these  late  cases  if  the  surgeon  contents 
himself  with  sponging  out  with  moist  gauze  such  food  particles  as  are 
readily  accessible. 

Some  patients  are  seen  so  late  after  perforation  occurs  that  it  seems 
evident  that  immediate  operation  will  only  hasten  the  exittis  lelhalis. 
If  these  patients  had  been  treated  from  the  time  of  occurrence  of  the 
first  symptoms  of  perforation  according  to  the  strictest  rules  of  the 
so-called  "Ochsner  treatment"  it  is  probable,  as  already  mentioned, 
that  I  per  cent,  of  them  might  recover  without  operation.     Perhaps 


126  GASTRIC  ULCER 

as  many  as  5  per  cent,  more  might  have  been  able  to  localize  the  infec- 
tion, and  would  eventually  come  to  operation  for  drainage  of  a  sub- 
phrenic or  perigastric  abscess.  As  they  have  come  into  our  hands 
heretofore,  they  have  been  moribund,  and  we  have  not  disturbed  their 
dying  moments  by  resort  to  what  in  these  circumstances  amounts  to  a 
cruel  and  a  useless  operation.  Seven  such  patients  (4  during  the  last 
ro  years),  who  have  been  under  observation  for  a  few  hours  before 
death,  have  perished  without  the  benefits  which  modern  medical 
science  affords  for  the  prevention  and  cure  of  peritonitis.  These 
deaths  are  not  chargeable  to  surgery  nor  to  the  surgeon,  but  to  the 
medical  men  into  whose  hands  these  miserable  patients  committed 
their  mortal  bodies. 

When  one  perforation  has  been  found  and  closed,  should  a  second 
perforation  be  looked  for?  Undoubtedly  it  should;  but  if  not  readily 
found  further  time  should  not  be  wasted  in  a  search  which  will  prove 
futile  in  four  out  of  live  cases  at  least,  especially  since  the  time  so  con- 
sumed may  be  more  profitably  spent,  we  believe,  in  the  performance 
of  gastro-jejunostomy. 

Gastro-jejunostomy  as  a  primary  operation  in  a  patient  with  gastric 
perforation  appears  to  have  been  first  employed  by  Braun  in  1897  when 
he  unexpectedly  found  a  perforation  in  a  patient  upon  whom  he  was 
preparing  to  do  a  gastro-enterostomy  for  pyloric  stenosis.  There  are 
two  reasons  for  performing  gastro-jejunostomy  as  a  primary  operation: 
first  to  promote  healing  of  the  perforated  area,  and  second  to  prevent 
recurrence  of  symptoms  or  a  subsequent  perforation.  Especially  im- 
portant is  a  primary  gastro-jejunostomy  if  the  perforation  is  close  to  the 
pylorus,  for  its  closure  will  then  be  very  likely  to  cause  obstruction,  if 
not  immediately,  at  any  rate  when  cicatrization  has  been  complete. 
There  are  two  important  questions  to  be  answered  in  this  connection. 
First,  does  the  adoption  of  gastro-jejunostomy  aft'ect  the  immediate 
mortality  of  the  operation  for  gastric  or  duodenal  perforation?  Second, 
does  its  adoption  affect  the  end-results? 

When  the  first  edition  of  this  work  was  published,  we  could  find  only 
22  instances- recorded  in  which  gastro-jejunostomy  had  been  employed 
as  a  primary  operation.  From  the  following  Table  it  is  very  evident  that 
it  is  now  accepted  by  many  surgeons  as  the  proper  procedure,  at  least 
in  selected  cases;  and  that  its  adoption,  taking  the  case  reports  in  gen- 
eral, does  not  adti  to  the  primary  mortality.  In  regard  to  the  end-re- 
sults less  certainty  exists,  as  the  reports  do  not  include  so  many  cases; 
moreover,  the  end-results  of  operations  without  primary  gastro-jejunos- 
tomy are  not  definitely  known.     Twenty  of  the  senior  author's  patients 


TREATMENT    OF   PERFORATION 


127 


Operations  for  Gastric  or  Duodenal  Perforation  with  Primary  Gastro-jejunos- 
STOMY.     Immediate  Mortality 


Operator 


i 


Ashhurst  (Episcopal  Hospital) 

Caird  (Edinb.  Med.  J.,  1914,  xiii,  455)  (Collective 

statistics) 

CoUinson  (Jour.  Am.  Med.  Assoc,  1914, 1-xiii,  1184)! 

Deaver  (Lankenau  Hospital) 

Galpern  (Arch.  f.  klin.  Chir.,  1910,  xciv,  870) 

Hartmann  andLecene  (Ann.  Surg.,  1914,  Ix,  227).  . 
Hess  (St.  Petersb.  med.  Woch.,  1910,  xxv,  600).  ... 

Kroiss  (Beitr.  z.  klin.  Chir.,  1910,  Ixvii,  509) 

Kummell   (Deutsch.   med.   Woch.,   1912,  xxxvii.  ' 

39S) 

Moynihan  (Duod.  Ulcer,  Phila.,  1912) 

Peck  (Jour.  Am.  Med.  Assoc,  1915,  Ixv,  659 

Struthers  (Edinb.  M.  J.,  1912,  ix,  505) 

Sullivan  (Jour.  Am.  Med.  .\ssoc.,  1916,  ii,  330). . . 


Operations 


Immediate 
mortality 
percent. 


117 

28.20 

27 

30.0 

44 

6.8 

7 

14.0 

4 

° 

5 

80.0 

6S 

21.5 

5 

20.0 

4 

25.0 

12 

0 

25 

25.0 

10 

0 

have  been  traced  for  more  than  a  year,  and  all  reported  themselves 
free  from  symptoms.  Among  Caird's  collected  cases  of  operation  for 
gastric  perforation,  in  only  29  of  which  primary  gastro-jejunostomy 
was  employed,  the  end-results  were  ascertained  in  85  patients,  as  may 
be  seen  below: 


Recovered  from 

Cases 

Xo 

Per 

operations 

traced 

symptoms      | 

cent. 

I899-I903 

17 

. 

7 

100. 0 

1904- 

1908 

ss 

36 

27 

75-0 

1909- 

1913 

64 

42 

42 

100. 0 

139 

S5 

76 

89.4 

Caird  found,  moreover,  that  among  40  patients  treated  by  suture 
alone,  no  less  than  19,  or  47.5  per  cent.,  were  later  reported  to  be  suf- 
fering from  dyspepsia;  while  of  52  treated  by  primary  gastro-jejunos- 
tomy, only  5,  or  less  than  10  per  cent.,  suffered  from  digestive  troubles. 
This  would  indicate,  he  argues,  that  primary  gastro-jejunostomy  pre- 
sents the  advantage  of  warding  off  dyspepsia.  The  records,  however, 
showed  no  evidence,  he  says,  that  in  any  of  the  fatal  cases  was  death 
due  to  the  omission  of  gastro-jejunostomy  or  that  the  omission  seriously 


128  GASTRIC  ULCER 

interfered  with  recovery.  English,  as  long  ago  as  1903,  traced  17  out 
of  24  patients  who  recovered  after  suture  of  a  gastric  perforation,  no 
gastro-jejunostomy  having  been  done  in  any  case:  of  these  17  patients, 
13  had  no  further  gastric  symptoms  and  4  were  dyspeptic,  presenting 
symptoms  not  of  acute  ulcer  but  of  a  cicatrix  and  adhesions. 

Most  surgeons  are  agreed  that  in  cases  where  closure  of  the  perfora- 
tion produces  stenosis  of  the  pylorus  it  is  advisable  to  adopt  gastro- 
jejunostomy as  a  primary  operation.  In  Caird's  duodenal  series  (88 
cases)  primary  gastro-jejunostomy  was  obligatory  in  39,  and  was  chosen 
in  49  other  cases  because  of  the  good  general  condition  of  the  patients 
after  closure  of  the  perforation.  The  latter  series  of  cases  comprised 
only  3  deaths,  a  mortality  rate  of  only  a  little  over  6  per  cent. 

Struthers  states  that  it  was  from  his  cases  in  which  gastro-jejunos- 
tomy was  obligatory  that  he  first  learned  how  beneficial  the  operation 
appears  to  be  in  promoting  the  patient's  comfort  during  recovery. 
He  traced  14  out  of  17  patients,  and  found  none  of  them  suffered 
from  serious  digestive  disturbance,  up  to  four  years  and  a  half  after 
operation  ;  but  of  3  cases  in  which  gastro-jejunostomy  was  not  done, 
two  patients  were  well  for  a  time,  but  later  developed  symptoms  of 
ulcer,  while  the  third  alone  remained  free  from  symptoms,  which  was 
his  condition  before  perforation  had  taken  place.  Sullivan  (1916) 
traced  5  out  of  10  patients  who  had  had  a  primary  gastro-jejunostomy, 
and  found  all  of  them  free  from  symptoms;  but  adds  that  he  did  not 
receive  a  similar  encouraging  report  from  three  other  patients  in 
whom  simple  closure  of  the  perforation  was  done.  Peck  (1915) 
concluded  that  his  study  of  the  end-results  in  a  series  of  cases  was  not 
of  much  value  in  finding  an  answer  to  the  question  of  whether  or  not 
primary  gastro-jejunostomy  should  be  employed.  He  adds  "It 
would  seem  fair  to  assume,  however,  that  primary  gastro-enterostomy 
in  properly  selected  cases  does  not  greatly  increase  the  immediate  mor- 
tality, and  that  it  should  increase  the  prospects  of  ultimate  cure." 
None  of  the  cases  in  his  series  treated  by  simple  suture,  however, 
required  secondary  operations  for  pyloric  stenosis.  Collinson  (1914) 
traced  9  patients,  gastro-jejunostomy  not  having  been  done  in  any: 
4  patients,  or  44  per  cent,  were  found  to  be  free  from  symptoms,  4  had 
had  a  secondary  gastro-jejunostomy  and  were  then  relieved  of  their 
indigestion,  and  i  still  had  ulcer  symptoms.  Of  the  4  patients  who 
submitted  to  secondary  gastro-jejunostomy  for  persistent  indigestion, 
only  I  was  found  to  have  true  pyloric  stenosis,  while  the  3  others 
merely  had  peripyloric  adhesions.  Collinson  also  traced  1 1  patients 
in  whom  gastro-jejunostomy  had  been  done  as  a  primary  operation: 


TREATMENT  OF  PERFORATION  I2Q 

of  these  9,  or  nearly  82  per  cent,  were  free  from  symptoms;  i  had  died 
since  of  carcinoma  of  the  esophagus,  and  i  had  been  operated  on 
recently  for  gastrojejunal  ulcer.  Collinson  extended  his  investiga- 
tions beyond  his  own  patients,  and  traced  also  17  patients  of  other 
surgeons,  in  whose  cases  p.rimary  gastro-jejunostomy  had  not  been 
employed :  13  were  free  from  symptoms,  4  had  recurrence  of  symptoms. 
Of  16  cases  with  primary  gastro-jejunostomy  10  were  free  from  symp- 
toms and  6  still  had  some  indigestion.  Combining  Collinson's  personal 
figures,  with  those  he  collected,  we  have  notes  of  the  end  results  of 

26  patients  without  gastro-jejunostomy  of  whom 

17  or  65  per  cent,  are  free  from  symptoms 
9  or  35  per  cent,  have  recurrence  of  symptoms 

27  patients  with  gastro-jejunostomy  of  whom 

19  or  70  per  cent,  are  free  from  symptoms 
7  or  26  per  cent,  have  recurrence  of  symptoms 
I  is  dead  of  another  cause. 

Collinson's  conclusion  as  to  the  adoption  of  primary  gastro- 
jejunostomy is  "When  in  doubt,  Dont." 

Gibson  (1916)  traced  7  patients  for  a  sufficient  length  of  time  after 
operation  to  ascertain  end-results:  none  of  these  had  a  primary  gastro- 
jejunostomy, and  only  one  suffered  after  operation  from  any  gastric 
symptoms,  and  in  this  case  they  were  really  negligible. 

Other  surgeons,  however,  have  not  been  so  fortunate.  Paterson 
(1906)  stated  that  among  the  cases  of  gastric  perforation  which  he 
collected,  no  less  than  13  deaths  out  of  a  total  of  58  could  almost  cer- 
tainly have  been  prevented  if  a  primary  gastro-enterostomy  had  been 
done;  indeed  Paterson  goes  further  than  we  should  be  incliiied  to  do, 
and  claims  that  even  purulent  peritonitis  is  no  contra-indication  to 
gastro-jejunostomy.  In  two  of  Caird's  cases,  this  operation  had  to  be 
done  three  days  after  suture  of  the  perforation,  on  account  of  pyloric 
stenosis;  Allingham  and  Thorpe  had  to  resort  to  it  one  month  later  to 
accelerate  their  patient's  convalescence;  Scudder  resorted  to  it  five 
weeks  after,  and  Gibbon  18  months  after  suture  of  the  gastric  perfora- 
tion. Mayo  and  Moynihan  have  had  a  similar  experience.  One  of 
us  (Ashhurst)  was  very  thankful  that  he  had  employed  it  as  a  primary 
operation  in  a  patient  in  whom  leakage  of  bile  from  the  perforation 
occurred  along  the  drainage  tract,  on  the  second,  third,  and  fourth 
days  after  operation;  the  gastrojejunal  anastomosis  permitted  prompt 
and  spontaneous  closure  of  the  duodenal  fistula,  with  recovery  of  the 
patient. 


1 30  GASTRIC  ULCER 

It  continues  to  be  our  opinion,  that  in  any  case  where  it  is  not 
specifically  and  positively  contra-indicated,  gastro-jejunostomy  should 
be  employed  as  a  primary  operation  in  patients  with  gastric 
perforation. 

Exploratory  Laparotomy. — Operations  undertaken  in  patients 
suspected  of  having  suffered  perforation  of  a  gastric  ulcer,  must  in 
the  nature  of  things  at  times  be  merely  explorations.  A  positive 
diagnosis  is  not  always  possible,  and  it  is  usually  more  to  the  patient's 
interest  for  the  surgeon  with  proper  facilities  at  his  disposal,  to  explore 
the  abdomen,  than  for  an  operation  to  be  postponed  until  the  advent  of 
unmistakable  peritonitis  renders  the  diagnosis  certain.  Gross  and 
Cross  in  their  extensive  review  of  the  literature  (1904)  found  records 
of  only  two  patients  who  died  after  being  subjected  to  a  laparotomie 
blanche,  as  it  has  been  called — that  is  to  say  a  laparotomy  in  which  no 
lesions  were  found  to  account  for  the  symptoms.  Nor  could  these  two 
solitary  deaths  be  attributed  to  the  exploratory  operation,  since  death 
in  one  was  due  to  persistent  hematemesis,  for  which  no  cause  could 
be  found,  and  in  the  other  was  caused  by  the  rupture  of  an  aortic 
aneurism.  Laparotomie  blanche  has  been  reported  by  Kirk  (3  cases), 
by  Enghsh  (3  cases,)  and  by  Korte  (2  cases).  English  also  mentions 
4  other  patients  in  whom  operations  were  undertaken  for  gastric 
perforation,  but  in  whom  the  symptoms  were  found  to  have  another 
cause. 

Esophageal  perforations  into  the  peritoneal  cavity  have  been 
recorded  by  Korte,  as  well  as  by  Mesnard  and  Feroualle.  Both 
patients  died. 


CHAPTER    V 

BENIGN  DISEASES  OF  THE  STOMACH  AND  DUODENUM 

(Continued) 

Pyloric  Obstruction 

Under  the  general  heading  of  pyloric  obstruction  it  is  convenient 
to  group  three  distinct  affections.  These  are  Infantile  Pyloric  Stenosis, 
Pylorospasm,  and  Gastric  Dilatation.  Although  pylorospasm  may 
possibly  be  considered  merely  a  symptom,  and  gastric  dilatation  a 
complication  or  a  consequence  of  gastric  ulcer,  yet  each  of  them  seems 
of  sufficient  importance  to  render  advisable  its  inclusion  within  the 
present  section. 

Infantile  Stenosis  of  the  Pylorus 

Congenital  Hypertrophy  of  the  Pylorus,  or  Hyperemesis  Lacfan- 
tium,  as  it  has  been  variously  called,  is  not  yet  a  distinct  pathological 
entity.  As  early  as  1788,  Beardsley  of  New  Haven  is  said,  on  the 
authority  of  Osier,  to  have  recognized  this  disease  clinically,  and  to 
have  described  his  findings  at  autopsy,  under  the  name  of  scirrhus  of 
the  pylorus.  Hirschsprung  in  1888  reported  a  case.  According  to 
Weber  (1910J,  surgical  treatment  was  first  adopted  in  1895,  by 
Cordua,  who  did  jejunostomy,  but  with  a  fatal  result.  In  1896 
Schwyzer  suggested  Loreta's  operation;  and  in  1897  Stern  operated 
by  gastro-enterostomy.  The  first  successful  operation,  also  by  gastro- 
enterostomy, was  performed  in  1898  byLobker.  Further  references  to 
the  literature  may  be  found  in  the  articles  of  Neurath  (1899),  Tran- 
tenroth  (1902),  Cautley  and  Dent  (1906),  and  Wachenheim  (1905). 

Because  there  is  not  yet  agreement  as  to  the  pathological  changes 
producing  the  symptomatology,  some  authors,  notably  Meinhard 
Schmidt,  have  preferred  to  retain  the  original  symptomatic  name 
Hyperemesis  Lactantium.  But  the  trend  of  modern  opinion  is  toward 
the  adoption  of  the  term  Infantile  Stenosis,  which  while  not  asserting 
that  the  condition  is  a  congenital  deformity,  as  some  have  maintained, 
nor  committing  the  writer  to  any  clearly  defined  pathology,  neverthe- 
less expresses  with  sufficient  accuracy  the  changes  usually  found  at 
operation  or  autopsy. 

131 


132  BENIGN  DISEASES  OF  THE  STOMACH  AND  DUODENUM 

Causes. — Three  theories  have  been  recognized  as  to  the  causation 
of  the  symptoms  about  to  be  described.  These  may  be  briefly  de- 
nominated the  congenital  abnormality  theory,  the  hypertrophy  theory,  and 
the  theory  of  simple  spasm.  The  first  asserts  that  the  pyloric  stenosis 
is  a  congenital  abnormality  quite  as  truly  as  hare-hp,  webbed  fingers, 
or  imperforation  of  the  anus.  Cautley  and  Dent  state  that  the  pyloric 
thickening  is  primary,  and  due  simply  to  a  redundance  of  tissue,  placed 
there  by  nature  as  the  result  of  over-exertion  in  forming  the  ordinary 
sphincter.  In  support  of  this  theory,  Xeurath  asserted  that  a  family 
predisposition  might  exist,  quoting  Henschel  who  observed  three,  and 
Ashby  who  observed  four  cases  in  the  same  family.  Moreover,  in  one 
of  Ashby's  cases  there  was  also  atresia  ani,  a  fact  which  Neurath  thinks 
lends  support  to  the  congenital  abnormality  theory,  not  to  that  of 
spasm  nor  to  that  of  h^^jertrophy.  Actual  atresia  of  the  pylorus  or 
duodenum  has  in  a  few  instances  been  found  at  autopsy  (Cleemann, 
Eastes,  Goodhart,  Habheggar,  Lesshaft,  etc.).  Should  it  by  any 
possibility  be  recognized  during  life,  it  would  of  course  be  susceptible 
of  operative  relief,  even  if  with  very  small  chance  of  success.  Maylard 
has  called  attention  to  congenital  narrowness  of  the  pylorus,  not  caused 
by  hyperplasia  of  the  pyloric  sphincter,  as  a  cause  of  indigestion  in 
young  adults;  Mayo  Robson  has  also  seen  it;  and  it  is  of  course  possible 
that  some  cases  of  hjperemesis  lactantium  may  be  due  to  a  similar 
condition.  But  that  the  symptoms  of  this  malady  are  very  rarely 
manifested  before  the  baby  is  a  week  old  at  least,  and  that  in  several 
instances  children  no  longer  infants  have  developed  the  disease  (Son- 
nenburg's  patient  was  six  j-ears  of  age),  are  facts  which  militate  strongly 
against  the  assumption  that  the  affection  is  due  solely  to  any  deformit)' 
existing  before  birth.  At  almost  every  autopsy  and  operation  at 
which  the  pylorus  in  these  patients  has  been  brought  to  view,  the 
actual  condition  has  been  found  to  be  one  of  increase  in  the  muscu- 
lar tissue,  particularly  the  circular  muscle  fibres  surrounding  the 
pyloric  opening  of  the  stomach,  with  edema.  And  what  lends  further 
support  to  the  theory  that  it  is  an  hypertrophic,  not  a  neoplastic,  over- 
growth, is  the  fact  that  on  the  gastric  side  the  thickening  is  not  sharply 
limited,  but  extends  for  some  distance  into  the  pyloric  portion  of  the 
stomach,  as  an  hypertrophic  overgrowth  might  be  expected  to  do,  since 
the  pyloric  antrum  would  naturally  be  involved  in  such  change;  whereas 
on  the  duodenal  side  the  thickening  ceases  suddenl}-,  and  within  a  very 
short  space  after  the  pylorus  is  passed  the  duodenum  has  been  found  to 
present  its  normal  characteristics. 

To  induce  this  hypertrophy  alleged  to  be  the  pathological  change, 


INFANTILE  STENOSIS  OF  THE  PYLORUS 


^33 


it  may  be  assumed  that  there  is  or  that  there  has  been  a  small  erosion 
or  fissure  in  the  pyloric  region  of  the  stomach,  and  that  there  has  also 
been  hyperacidity  of  the  gastric  juice.  That  these  factors,  so  well 
known  as  causes  of  pylorospasm  in  the  adult,  should  in  the  infant  be 
provocative  of  a  like  change,  appears  in  no  way  unreasonable;  and  if  it 
be  objected  that  sufficient  time  does  not  elapse  between  birth  and  the 
occurrence  of  the  hypertrophy  for  it  to  be  explained  on  these  grounds, 
it  may  with  perfect  justice  be  replied  that  infantile  tissues  cannot  always 
be  judged  by  standards  derived  from  adult  life.  John  Thomson,  the 
well  known  pediatrist,  has 
supported  the  theory  of 
hypertrophy  due  to  incoor- 
dination of  the  muscle  during 
fetal  life,  and  Jedlicka  also 
maintains  that  prolonged 
spasm  may  induce  hyper- 
trophy. Meinhard  Schmidt 
compares  the  condition  to 
that  of  vaginismus,  tenesmus 
ani,  and  blepharospasm  which 
are  frequently  caused  by  fis- 
sure or  ulcer.  Yet  no  hyper- 
trophy occurs  in  such  cases, 
and  RoUeston  reminds  us  that 
no  hypertrophy  of  the  pylorus 
is  found  in  Reichmann's  dis- 
ease, gastro-succorhea,  which 
is  usually  accompanied  by 
before,   it  is  not  always  safe 


Fig.  37. — Infantile  Stenosis  of  tlie  Pylorus. 
Natural  Size.  Note  the  Thickened  Sphincter  and 
the  Fold  of  Mucous  Membrane  Occluding  the 
Orifice.      (After  Cautley  and  Dent.) 


pylorospasm.  But  as  has  been  said 
to  argue  from  adult  to  infantile  con- 
ditions. Pfaundler,  while  not  denying  the  presence  in  some  of  these 
patients  of  increase  of  muscular  tissue,  considers  the  condition  in 
most  instances  merely  one  of  spasticity.  Heubner,  from  a  study  of 
41  cases  encountered  among  10,000  children,  concludes  that  the  affec- 
tion is  due  to  pylorospasm  causing  hypertrophy.  And  Pfaundler  now 
recognizes  the  existence  of  two  forms — hypertrophic  and  spasmodic — 
the  latter  being  intermittent  in  character.  Our  own  tendency  is  to 
hold  that  the  unquestionable  increase  in  muscular  tissue  is  in  the  nature 
of  an  hypertrophy,  and  is  brought  about  by  persistent  spasm  due  to 
irritation  from  one  cause  or  another.  Similar  changes  might  be  expected 
to  be  encountered  occasionally  in  other  portions  of  the  gastro-intestinal 
tract;  and  as  a  matter  of  fact  one  of  us  (Ashhurst)  has  recorded  (191 7) 


134  BENIGN  DISEASES  OF  THE  STOMACH  AND  DUODENUM 

under  the  name  ileo-cecal  infaiiiile  stenosis,  precisely  an  analogous 
condition. 

The  redundance  of  mucous  membrane,  to  be  presently  alluded  to, 
may  act  itself  so  as  to  provoke  spasm,  much  as  a  polypus  does  in  the 
same  and  in  similar  situations.  It  should,  perhaps,  be  noted  that 
Wernstedt  (1907)  tried  to  explain  the  presence  of  this  mucous  fold  by 
studies  in  comparative  anatomy.  The  existence  of  primary  stenosis 
of  moderate  degree,  from  a  congenital  abnormality  of  the  pyloric 
musculature,  is  held  by  Downes  to  be  quite  sufficient  to  e.xplain  the  sub- 
sequent development  of  the  pyloric  tumor  through  the  action  of  spasm 
inducing  hypertrophy  and  edema. 

It  is  to  be  hoped  that  further  study,  both  clinical  and  microscopical, 
will  elucidate  these  questions,  and  place  the  pathology  of  this  serious 
condition  on  a  lirm  basis.  Until  then  we  must  be  content  to  theorize 
as  to  the  causes,  and  proceed  as  best  we  may,  empirically,  to  adopt 
uncertain  treatment  for  fairly  characteristic  symptoms. 

The  usual  appearance  of  the  parts  involved  is  very  well  shown 
in  Figure  37,  copied  from  Cautley  and  Dent's  article.  At  first  glance 
the  resemblance  to  an  enlarged  prostate  with  the  bladder  attached, 
is  quite  striking;  and  this  becomes  greater  when  on  more  careful 
examination  we  see  a  fold  of  mucous  membrane  which  corresponds 
very  closely  in  appearance  to  the  uvula  vesica .  This  mucous  fold  is  a 
characteristic  feature  of  infantile  pyloric  stenosis,  and  often  renders 
nearly  complete  the  obliteration  of  the  passage  from  the  stomach  to 
the  duodenum,  even  when  the  mere  muscular  mass  would  with  ease 
permit  the  passage  of  a  probe  through  the  pylorus.  Meinhard  Schmidt 
(1901)  estimated  the  calibre  of  the  normal  pylorus  at  birth  as  admit- 
ting a  No.  19  French  sound,  and  as  increasing  one  number  of  the 
French  scale  (or  one-third  of  a  milUmetre  in  diameter)  for  each 
month  of  life;  so  that  a  diameter  of  nine  millimetres,  equal  to 
No.  27  of  the  French  scale,  would  be  normal  for  a  child  of  eight  or 
nine  months  of  age,  and  at  twelve  months  of  age  the  normal  pylorus 
should  admit  a  No.  32  F.  sound.  According  to  Fisk,  Still  has  stated 
that  at  six  months  of  age  the  normal  pyloric  wall  is  about  2.5  mm. 
thick;  while  in  hypertrophic  stenosis  it  has  been  found  to  vary  from 
3.5  to  5.7  mm.  in  thickness.  Strauss  (1918)  has  observed  that  in- 
variably the  tumor  is  larger  the  older  the  baby,  being  small  in  infants 
3  to  4  weeks  old  and  large  in  those  of  7  to  12  weeks. 

In  only  a  few  instances  have  there  been  any  microscopical  evidences, 
even  slight,  of  acute  inflammation;  so  that  with  our  present  knowledge 
we  are  limited  to  the  theories  already  mentioned  of  neoplastic  and 


INFANTILE    STENOSIS    OF    THE    PYLORUS  135 

hypertrophic  overgrowth,  the  latter  seeming  the  more  reasonable  of  the 
two. 

Symptoms. — The  symptoms  of  this  affection  do  not  differ  mate- 
rially from  those  of  the  same  condition  in  adults.  The  chief  subjective 
signs  are  vomiting  and  constipation,  and  the  chief  objective  signs 
are  a  pyloric  tumor  and  visible  gastric  peristalsis.  The  vomiting 
usually  does  not  begin  until  the  baby  is  about  a  week  or  ten  days  old, 
though  in  rare  instances  it  has  been  noted  from  birth,  or  has  not  ap- 
peared for  a  month  or  more.  In  the  earliest  stages  liquids  may  be 
rejected  almost  as  soon  as  they  are  swallowed.  The  vomiting  is  nearly 
invariably  cumulative  as  well  as  projectile,  when  the  disease  has  lasted 
more  than  a  few  weeks;  that  is  to  say,  three  or  four  feedings  will  be 
retained,  and  then  after  the  last  feeding  the  whole  of  the  gastric  con- 
tents will  be  rejected  at  once.  Hyperacidity  is  usually  present.  Bile 
is  conspicuous  by  its  absence  from  the  vomitus.  The  lack  of  absorp- 
tion accounts  for  the  constant  hunger,  the  persistent  constipation,  and 
the  progressive  emaciation.  These  babies  should  be  weighed  at 
regular  intervals.  There  is  no  other  method  which  so  surely  shows  the 
loss  of  flesh.  As  emaciation  proceeds  and  the  vomiting  becomes  more 
marked,  as  it  usually  does,  there  is  as  a  rule  very  little  difficulty  in 
detecting  a  pyloric  tumor;  indeed  this  is  frequently  visible  to  the  most 
casual  glance,  projectmg  from  the  sunken  and  withered  belly  in  a  char- 
acteristic manner.  Close  observation  will  now  usually  detect,  sometimes 
only  at  long  intervals,  peristaltic  waves  in  the  stomach,  commencing 
in  the  left  hypochondriac  region,  passing  across  the  epigastrium,  and 
culminating  in  the  pyloric  tumor  which  sometimes  may  be  felt  to 
become  denser  on  contraction.  At  rare  intervals  a  peristaltic  wave  may 
pass  beyond  the  stenosed  pylorus,  and  diffuse  itself  through  the  small 
intestines,  but  as  a  rule  the  visible  contraction  ceases  at  the  pylorus. 
When  this  stage  is  well  advanced,  gastric  dilatation  commences, 
and  may  become  excessive.     It  is  recognized  by  the  usual  signs. 

Tetany  is  a  symptom  noted  in  some  cases. 

Prognosis. — It  is  difficult  to  reach  definite  conclusions  as  to  the 
prognosis  of  a  disease  about  the  pathology  of  which  so  little  is  known. 
If  we  follow  some  authors  in  placing  every  case  of  rebellious  infantile 
vomiting  in  this  category,  the  prognosis  will  be  fairly  good,  since  the 
largest  proportion  of  such  babies  soon  recover  when  their  diet  is  regu- 
lated in  quaUty  and  in  quantity.  If,  on  the  other  hand,  we  claim  that 
all  infants  who  recover  without  operation  never  had  pyloric  stenosis, 
or  assert  with  Cautley  and  Dent  that  unless  operated  on  all  these 
patients  die  before  they  are  four  months  of  age — tlien,  under  these 


136  BENIGN  DISEASES  OF  THE  STOMACH  AND  DUODENUM 

circumstances,  we  repeat,  the  prognosis  must  be  considered  grave. 
And  on  our  lundamental  belief  as  to  tlie  gravity  of  the  prognosis  our 
ideas  as  to  surgical  treatment  must  be  based.  It  is  probably  safe  to 
assert  with  Meltzer  that  if  these  infants  survive  without  operation 
more  than  four  months  their  grade  of  stenosis  must  have  been  slight.' 

Treatment. — It  is  needless  to  say  that  medical  treatment  always 
is  tried  first;  but  it  is  our  belief  that  in  the  majority  of  cases  medical 
treatment,  no  matter  how  promptly  instituted  and  energetically 
applied  will  be  unsuccessful  in  curing  the  patient.  If  the  views  as 
to  'the  pathology  of  the  affection  set  forth  in  these  pages  be  correct, 
that  the  thickening  is  not  neoplastic,  but  is  developed  as  the  result 
of  irritation  of  some  kind  or  another,  then  there  is  reason  to  think 
that  medical  treatment  may  in  some  cases  be  able  to  prevent  the  hyper- 
trophic overgrowth  of  muscle  tissue;  but  it  is  very  doubtful  if  it  is 
ever  able  to  arrest  it  and  to  cause  its  disappearance  after  the  hyper- 
trophy has  once  developed.  It  is  true  that  cures  have  resulted  even 
in  advanced  cases,  under  judicious  medical  treatment;  but  they  are  ex- 
tremely exceptional.  Against  the  figures  of  Neurath  (1899),  who 
collected  41  cases  of  pyloric  stenosis  in  infants  less  than  twelve  months 
old,  all  of  whom  died  under  medical  treatment,  may  be  opposed  the 
best  results  of  medical  treatment  as  represented  by  the  following  reports: 
Walls  reports  nine  cases  treated  without  operation,  with  3  deaths; 
Lowenburg  informs  us  of  a  series  of  14  cases  treated  without  operation, 
with  5  deaths.  Now  in  both  of  these  recent  series  of  cases  it  is  to  be 
presumed  that  operative  treatment  was  available,  even  for  the  patients 
who  died;  and  that  among  the  patients  who  recovered  without  opera- 
tion there  were  a  number  with  such  a  slight  degree  of  stenosis  that 
operation  need  never  have  been  seriously  considered.  Hence  the 
inference  is  plain  that  taking  any  series  of  fully  developed  cases,  the 
mortality  following  non-operative  treatment  is  shockingly  high.  It 
remains  for  us  to  show  what  is  the  mortality  following  surgical 
treatment. 

The  most  important  fact  to  be  learned  from  the  surgical  statistics 
published,  is  that  the  earlier  an  operation  is  done,  when  once  it  has  been 
determined  upon,  the  greater  is  the  chance  of  success.  Progressive 
loss  of  weight  is  the  most  imperative  indication  for  operation.  Unless 
weight  is  being  lost  it  is  almost  certain  that  a  sufficient  amount  of 
nourishment  is  being  absorbed  to  sustain  life,  no  matter  how  constant 
and   copious   the  vomiting  may   seem  to  be.     Fluoroscopy  will  show 

'  Four  out  of  fifty  patients  under  the  care  of  H.  C.  Deaver  (1920)  recovered  without 
operation;  among  the  remainder,  all  of  whom  were  operated  on,  there  were  four  deaths. 


INFANTILE    STENOSIS    OF    THE    PYLORUS  137 

how  much  of  an  ingested  opaque  meal  is  discharged  through  the  stenosed 
pylorus;  if  at  least  two-thirds  of  the  meal  has  passed  through  the 
pylorus  within  three  hours,  it  is  not  likely  that  operation  will  be  required. 

When  surgical  intervention  has  been  decided  upon,  it  then  becomes 
necessary  to  select  some  form  of  operation;  and  in  doing  this  we  should 
be  guided  not  only  by  the  change  in  the  stomach,  but  also  by  the  tender 
age  of  the  patient.  The  operations  employed  oftenest  have  been  py- 
loroplasty (and  various  modifications  of  this  operation),  and  gastro- 
jejunostomy. 

Bunts  (1908)  collected  69  cases  of  gastro-jejunostomy  for  infantile 
pyloric  stenosis,  with  37  deaths,  a  mortality  of  more  than  53  per  cent. 
Individual  surgeons,  however,  especially  Downes,  Richter  and  Scudder 
have  had  much  better  results. 

The  operation  of  choice  we  believe  is  Rammstedl's  method  of  pyloro- 
plasty. No  other  methods  of  pyloroplasty,  even  NicoU's,  has  given  such 
uniformly  satisfactory  results.  Rammstedt's  first  operation  (191 2)  was 
modelled  on  two  experiences  of  Weber's,  which  had  been  reported  in  1 910. 
Weber,  in  1908  and  1909,  operating  on  babies  with  pyloric  stenosis, 
and  attempting  to  do  an  ordinary  Heineke-Mikulicz  pyloroplasty 
but  without  opening  the  mucosa  of  the  stomach,  found  that  the  sutures 
would  not  hold  in  the  friable  tissues  when  he  came  to  close  his  longitu- 
dinal pyloric  incision  in  a  transverse  direction.  He  was  content  to 
cover  the  pouting  mucosa  with  an  omental  graft.  Both  his  patients 
recovered.  Rammstedt  did  the  same  operation  without  making  any 
attempt  to  suture  his  longitudinal  incision  in  the  pylorus,  and  he  left 
the  unopened  mucosa  pouting  into  the  gap.  His  patient  likewise  recov- 
ered. This,  it  will  be  seen  is  an  even  simpler  form  of  pyloroplasty 
than  that  adopted  by  NicoU,  which,  according  to  statistics  published 
in  the  first  edition  of  this  work,  was  attended  up  to  that  time  with  the 
lowest  mortality  (15.38  per  cent.)  of  any  operation  for  infantile  stenosis 
of  the  pylorus. 

NicoU's  pyloroplasty  is  done  as  follows:  An  incision  is  made  in  A 
or  V-shape  (transverse  to  the  long  axis  of  the  pylorus)  down  to  the 
mucosa,  which  is  not  opened.  The  pylorus  is  then  forcibly  divulsed 
by  forceps  introduced  through  a  separate  incision  in  the  anterior  wall 
of  the  stomach.  The  incision  in  the  pylorus  is  then  closed  so  as  to 
make  a  A  or  Y-shaped  scar,  thus  increasing  its  breadth  at  the  expense 
of  its  length.  It  is  probable  that  the  divulsion  of  the  pylorus  is  un- 
necessary.    Nicoll  (1906)  reported  13  operations  with  only  2  deaths. 

Rammstedt's  pyloroplasty  is  done  as  follows:  A  longitudinal  incision 
is  made  in  the  anterior  upper  wall  of  the  pylorus,  in  the  least  vascular 


138  BENIGN  DISEASES  OF  THE  STOMACH  AND  DUODENUM 

Gastroenterostomy  for  Infantile  Stenosis  of  the  Pylorus 


Operator                               Operations 

Deaths 

Mortalitj' 
per  cent. 

Deaver  (1920)' 12 

Do\vnes  (1916) 31 

Richter  (1914) '             19 

Scudder  (1914) 17 

2 

2 

3 

16.6 

35-0 
lo-S 
17.6 

Rammstedt's  Pyloroplasty  for  Infantile  Stenosis  op  the  Py'lorus 


Operator 


Operations 


Mortality 
per  cent. 


Deaver  (1920)* 

Downes  (1920) 

Gallic  and  Robertson  (191 7) 

Gray  and  Pirrie  (1919) 

Mixter  (1916,  in  Binnie's  Operative. 

Surgery) 

Strauss  (1918) 


46 

175 
16 

17 


8.7 
17. 1 
31.0 
41.0 

12. s 
4.6 


1  Eight  of    the  gastroenterostomies  and  all  of    the  Rammslcdt   operations  were  by 
Dr.  H.  C.  Deaver.     There  was  a  series  of  18  Rammstedt  operations  without  a  death. 
-  Three  patients  moribund  before  operation. 
'  Strauss  says  24  of  these  patients  were  moribund  before  operation. 


region,  extending  from  healthy  stomach  wall  past  the  pyloric  tumor 
(Fig.  38).  As  the  tumor  stops  abruptly  at  the  duodenal  end  great  care 
is  necessary  not  to  open  the  mucosa  in  the  latter  situation.  The 
incision  is  carried  down  carefully  through  the  muscular  coats  until 
the  mucosa  pouts  into  the  wound.  It  is  permissible  to  use  the  handle 
of  the  scalpel  or  the  blunt  ends  of  scissors  (Fig.  39)  to  detach  the  mus- 
cular walls  slightly  from  the  underhing  mucosa,  but  it  is  better  not  to 
attempt  too  much.  Strauss  (1915)  uses  only  the  handle  of  the  scalpel 
after  incising  the  serous  coat  of  the  pylorus.  The  incised  muscular 
walls  gape  widely,  and  the  mucous  membrane  pouts  into  the  incision. 
Nothing  more  is  done  except  to  close  the  abdominal  wall,  the  incision 
in  which  need  not  exceed  4  cm.  in  length.  The  operation  takes  from 
ten  to  fifteen  minutes.  The  baby  should  lie  on  a  hot  water  bottle, 
should  be  well  covered,  and  the  abdominal  wall  should  be  prepared 
before  ether  is  given  Haggard  (191S)  employs  only  local  anesthesia. 
Strauss  (1918)  has  modified  this  operation  by  shelling  out  two  flaps  of 
muscular  tissue  from  the  tumor  and  suturing  these  over  the  redundant 
and  prolapsed  mucous  membrane  (Fig.  40). 

It  is  perhaps  needless  to  add  that  most  of  the  deaths  following  this 


INFANTILE  STENOSIS  OF  THE  PYLORUS 


139 


simple  form  of  operation  have  been  due  not  to  the  shock  of  operation, 
nor  to  its  after  effects,  but  to  the  fact  that  it  was  employed  too  late. 
In  one  of  Downes's  fatal  cases  the  cause  of  the  pyloric  obstruction 
which  had  not  been  relieved  by  operation  was  found  at  autopsy  to  be  a 
mucous  polyp  which  blocked  the  canal  hke  a  ball-valve.  This  was  not 
a  true  case  of  infantile  stenosis  of  the  pylorus,  and  there  was  no  true 
muscular  hypertrophy.  Among  19  cases  in  which  Downes  added 
divulsion  of  the  pylorus  (as  in  Nicoll's  operation)  to  the  simple  Ramm- 


FlG.    38. 


Fig.  39. 
Figs.  38  and  39. — Rammstedt's  Method  of  Pyloroplasty. 

stedt  procedure,  there  were  two  deaths  from  peritonitis.  He  has  now 
abandoned  divulsion  and  finds  the  results  quite  as  good,  without  the 
risk  of  peritonitis. 

In  his  latest  statistics,  which  include  a  number  of  operations  by 
Matthews,  he  has  counted  as  operative  deaths  all  patients  dying  in 
the  hospital  even  though  several  died  from  gastroenteritis  two  to  four 
weeks  after  the  operation. 

Several  surgeons  have  had  an  opportunity  to  examine  the  pylorus 
some  weeks  or  months  after  operation,   the  patient  having  died   of 


140 


BENIGN  DISEASES  OF  THE  STOMACH  AND  DUODENUM 


intercurrent  disease.  Thus  Ransohoff  and  Wooley  (191 7)  found  six 
months  after  operation  that  the  tumor  mass  had  disappeared,  and  that 
the  site  of  the  operative  incision  in  the  pylorus  presented  a  linear  scar. 
In  Gallic  and  Robertson's  patient  (191 7),  examination  six  weeks  after 
operation  showed  no  change  in  size  of  the  tumor;  while  histological 
study  of  the  specimen  showed  that  the  peritoneal  covering  of  the 
pylorus  had  grown  down  into  the  operative  incision,  meeting  on  the 
exposed  mucosa.  Separating  the  lumen  of  the  pylorus  from  the  peri- 
toneal cavity  at  this  point  was  the  mucosa,  submucous  areolar  tissue, 
muscularis  mucosae,  a  small  quantity  of  white  fibrous  tissue,  and  peri- 


FiG.  40. — Strauss's  Method  of  Pyloroplasty:  A,  after  Incising  the  Serous  Coat,  the 
Muscle  is  Separated  down  to  the  Mucosa  by  the  Handle  of  the  Scalpel.  B,  The  Muscle  is 
Separated  from  the  Mucosa  around  almost  th^  entire  Circumference.  C,  Flaps  are  Formed 
from  the  Hypertrophied  Muscle  Tissue,  and  D.  are  Sutured  over  the  Mucous  Channel  which 
Expands  with  Obliteration  of  its  Folds. 

toncuni.  In  another  patient,  also,  who  died  of  intercurrent  disease 
about  one  year  after  the  operation  they  found  that  the  pyloric  enlarge- 
ment persisted,  though  its  relative  size  compared  to  the  normal  in- 
testines, was  somewhat  smaller  than  at  the  time  of  operation.  Downes 
(1920)  reports  that  autopsies  on  two  patients  who  died  of  pulmonary 
conditions  iS  months  after  leaving  the  hospital  showed  that  the  pyloric 
tumors  had  entirely  disappeared. 

Gastro-jejunostomy  appears  to  be  no  more  certain  to  bring  relief, 
and  is  undoubtedlv  a  more  formidable  undertaking  in  infants  than  is 


PYLOROSPASM  ■  I4I 

Rammstedt's  method  of  pyloroplasty;  and  we  believe  at  the  present 
day  the  surgeon  must  be  bold  indeed  to  employ  the  former  method. 

Eleven  of  the  patients  operated  upon  by  the  senior  author,  or  his 
brother  H.  C.  Deaver,  have  been  traced  a  sufficient  time  after  operation 
to  be  reckoned  as  end  results:  all  were  entirely  relieved. 

Pylorospasm 

This  is  an  intermittent  or  constant  contraction  of  the  pyloric 
sphincter,  attended  by  more  or  less  evident  symptoms.  It  is  really 
only  a  symptom  of  some  other  malady,  or  of  one  of  a  number  of  diseases 
met  with  in  the  abdomen.  It  will  be  noted  that  in  the  definition  of 
pylorospasm  it  is  stated  to  be  an  intermittent  or  constant  contraction 
of  the  sphincter.  It  is  very  rarely  a  remittent  contraction:  that  is  to 
say,  the  spasm  may  occur  only  once  or  twice  in  a  person's  lifetime — 
it  may  be  a  spasm  which  "comes  back  at  times;"  or  it  may  be,  and 
more  frequently  is,  an  intermittent  contraction — one  which  "goes 
away  at  times;"  and  in  rare  instances  the  spasm  may  be  constant 
■  for  a  period  of  two  or  three  days  or  longer,  without  any  intermission. 
The  first  form  is  that  which  is  a  frequent  accompaniment  of  gall-stone 
colic;  and  may  occur  in  other  acute  abdominal  affections,  as  appendi- 
citis, being,  here,  as  under  other  circumstances,  merely  a  symptom  of 
an  organic  lesion  of  the  alimentary  canal. 

In  many  cases  the  pain  of  the  cramp  is  not  very  great,  amount- 
ing merely  to  a  lively  sense  of  discomfort  in  the  epigastric  region, 
and  being  overshadowed  by  symptoms  of  "peristaltic  unrest  of  the 
stomach,"  so  graphically  described  by  Kussmaul  (1880)  ("embarras 
gastrique"  of  the  French).  WTien  the  pylorus  contracts  spasmod- 
ically, from  whatever  source  of  irritation  there  may  be  present,  the 
stomach  meets  with  an  insuperable  obstacle  to  its  evacuation. 
Peristaltic  unrest  ensues,  flatulence  develops  from  fermentation  and 
from  swallowed  air,  and  finally,  when  the  limit  of  endurance  is  reached, 
the  pylorus  relaxes  and  gastric  contents  pass  out  into  the  duodenum, 
or  the  patient  is  reUeved  of  his  distress  by  vomiting,  and  comparative 
comfort  is  restored. 

Such  a  crisis  as  this  may  occur,  as  already  remarked,  only  once 
or  twice  in  a  patient's  lifetime;  or  it  may  be  the  habitual  sequel  to  every 
meal.  The  symptoms  may  vary  from  those  of  the  mildest  gastric 
indigestion,  to  the  most  awful  and  overwhelming  pain  in  the  region  of 
the  pylorus.  The  pain  is  a  symptom  of  disease  somewhere  in  the  course 
of  the  mid-gut  or  its  appendages. 


142  BENIGN   DISEASES    OF    THE    STOMACH   AND    DUODENUM 

It  is  not  always  possible  to  determine  just  what  is  the  underlying 
disease  in  cases  of  pylorospasm.  It  is  probably  more  often  due  to  an 
erosion  or  ulcer  of  the  stomach  or  pyloric  antrum  than  to  any  other  single 
affection;  but  as  already  remarked,  it  is  a  frequent  accompaniment  of 
affections  of  the  gall-bladder  and  vermiform  appendix;  and  may  be  the 
only  distinctive  symptom  in  patients  with  polypus  of  the  stomach. 
Until  further  investigation  teaches  us  more,  we  must  be  content  in  the 
majority  of  cases  to  treat  the  condition  empirically. 

If  the  pylorospasm  persists,  intermittently,  over  a  long  period, 
it  is  wont  to  be  accompanied  by  symptoms  of  Reichmann  's  disease — 
excessive  secretion  of  the  stomach,  gastro-succorrhea;  but  whether 
this  disease  is  a  sequel  or  a  cause  of  pylorospasm  physicians  are  not 
agreed;  and  a  further  discussion  of  the  subject  would  be  out  of  place 
in  a  work  of  this  kind.  Gastric  dilatation  may  also  follow;  and  it 
would  not  be  improbable  that  hypertrophy  of  the  pyloric  sphincter 
might  be  a  sequel  of  long  standing  pylorospasm  in  some  patients, 
though  we  are  not  aware  that  such  a  change  has  ever  been 
demonstrated. 

Pylorospasm  can  be  certainly  detected  by  fluoroscopy  after  the 
ingestion  of  an  opaque  meal;  but  even  when  the  diagnosis  is  thus  de- 
cided, the  cause  may  remain  undetected. 

Pylorospasm  should  first  be  treated  energetically  by  medical 
means;  and  in  cases  where  reasonable  persistence  along  this  line  fails, 
surgical  intervention  must  be  considered.  In  all  cases  the  condition 
of  the  appendix,  as  well  as  of  the  upper  abdominal  organs,  should  be 
investigated  and  appropriate  operative  treatment  should  be  adopted. 

Gastric  Dilatation 

Although  the  interest  of  the  surgeon  in  gastric  dilatation  is  usually 
coniined  to  those  forms  which  are  strictly  secondary  in  origin,  and  which 
are  in  the  immense  majority  of  cases,  if  not  in  all,  produced  by  pyloric 
obstruction;  and  although  for  this  reason  it  has  seemed  best  to  dicuss 
the  subject  under  the  general  heading  of  obstruction  of  the  pylorus,  yet 
there  are  certain  forms  of  dilatation  of  the  stomach  which  have  of  late 
years  come  within  the  surgical  horizon,  and  yet  which  are  not  techni- 
cally due  to  obstruction  of  the  pylorus.  We  refer  to  acute  dilatation  of 
the  stomach,  and  to  the  form  known  to  physicians  as  atonic  dilatation 
or  gastric  myasthenia. 

Acute  Dilatation  of  the  Stomach,  lirst  brought  to  the  attention  of 
the  medical  world  in  1872  by  Hilton  Fagge,  has  been  discussed  in  elabo- 


ACUTE    DILATATION    OF    THE    STOMACH  143 

rate  articles  by  Neck  (1905),  by  Conner  (1907}  and  by  Laffer  (1908), 
the  last  named  having  collected  217  cases;  Ruth  has  more  recently 
(1913)  collected  100  cases,  which  he  has  analyzed  in  a  most  instructive 
paper. 

It  is,  as  already  remarked,  primarily  a  medical  disease.  It  is  met 
with  as  a  complication  in  various  infectious  diseases,  such  as  pneumonia 
and  typhoid  fever,  but  occasionally  seems  to  arise  as  a  primary  affec- 
tion, the  patient  being  suddenly  seized  with  symptoms  of  obstruction, 
and  there  being  no  preceding  disease  of  any  kind.  More  often,  how- 
ever, and  this  is  what  has  drawn  surgical  attention  to  it,  the  dilatation 
develops  as  a  post-operative  compUcation,  and  in  many  cases  terminates 
fatally  within  twenty-four  to  forty-eight  hours.  The  preceding  oper- 
ation is  by  no  means  always  an  abdominal  one.  Operations  on  the  ex- 
tremities, on  the  kidneys,  and  on  other  parts  of  the  body  have  been 
followed  by  acute  dilatation  of  the  stomach;  but  a  large  number  of  post- 
operative cases  have  followed  operations  on  the  biUary  tract. 

Causes. — Various  theories  have  been  advanced  to  explain  the  con- 
dition, and  their  number  shows  that  no  one  can  be  considered  wholly 
sufficient  to  explain  its  development  under  the  different  circumstances 
in  which  it  is  encountered.  As  predisposing  causes  have  been  recog- 
nized: atonic  dilatation  of  the  stomach;  pyloric  obstruction  whether 
associated  or  not  with  chronic  gastrectasis;  overhlling  of  the  stomach 
with  food  or  drink  (lemonade  in  some  and  champagne  in  others  have 
been  accused  as  exciting  causes);  preexisting  toxemias  (typhoid  fever, 
pneumonia,  etc.);  and  lastly  surgical  operations.  Routier  (1905) 
apparently  thought  all  post-operative  cases  could  be  attributed  to  septic 
intoxication;  but  while  it  must  be  acknowledged  that  in  most  instances 
when  the  condition  is  of  long  duration  pronounced  toxemia  is  present 
there  have  been  very  many  patients  with  no  evidence  of  sepsis.  Ruth 
attributes  the  condition  to  toxic  paresis  of  the  stomach  and  upper 
bowels,  often  predisposed  to  by  long  anesthetization  and  operative 
trauma.  Most  patients  are  between  twenty  and  thirty  years  of  age. 
Zade  adds  to  the  predisposing  causes  already  mentioned,  that  of  ab- 
normal length  of  the  mesentery,  or  a  position  of  the  small  bowels  in 
the  pelvis,  thus  pulling  on  the  mesentery.  Indeed  the  theory  proposed 
by  Hanau-Albrecht  in  1899,  that  acute  gastric  dilatation  is  due  to 
constriction  of  the  duodenum  by  the  superior  mesenteric  artery,  through 
dragging  on  the  root  of  the  mesentery,  still  receives  support.  But 
most  authors  think  that  the  dilatation  is  primary,  and  that  it  is  merely 
increased  by  kinking  of  the  pylorus  or  by  the  distended  stomach  itself 
pressing  on  and  occluding  the  duodenum.     The  observations  of  Kelling 


144  BENIGN   DISEASES    OF    THE    STOMACH   AND    DUODENUM 

and  others,  referred  to  in  Chapter  II,  as  to  the  gastro-duodenal  reflex, 
by  which  evacuation  of  the  stomach  is  prevented  by  distention  of  the 
duodenum,  have  probably  a  close  bearing  on  this  subject;  and  since  in 
many  cases  which  have  come  to  autopsy  there  has  been  found  (Neck, 
1905)  some  obstruction  to  the  duodenum  at  its  junction  with  the  jejunum, 
and  but  rarely  has  there  been  found  pyloric  obstruction,  it  seems 
only  fair  to  conclude  that  the  mechanical  obstruction  thus  produced 
is  at  least  as  sufficient  an  explanation  as  is  the  assertion  that  the  dila- 
tation is  primary,  or  due  to  some  lesion  of  the  pneumogastric  nerves, 
as  suggested  by  Carrion  and  Hallon  (1895).  Laffer  also  supported 
this  theory.  It  is  not  improbable,  we  admit,  that  in  those  cases  of 
acute  gastric  dilatation  developing  after  operations  on  the  biliary 
tract,  there  may  have  been  produced  some  reflex  disturbances  of  gastric 
innervation  by  way  of  the  splanchnics  and  the  hepatic  plexus;  j'et  we 
are  totally  unable  to  see  how  a  similar  explanation  could  by  any  stretch 
of  the  imagination  be  considered  applicable  to  the  cases  of  those  patients 
who  had  had  operations  performed  on  their  lower  extremitites.  It 
appears  to  us  that  it  is  a  much  more  likely  thing  that  the  anesthetiz- 
ation, and  the  hfting  of  the  patient  on  and  off  the  stretcher  and  the 
operating  table,  added  to  the  frequently  unusual  and  strained  positions 
in  which  patients  lie  during  and  after  operation,  are  all  factors  which 
would  tend  to  produce  an  enteroptosis  of  the  small  intestines,  or  would 
in  some  way  produce  a  kink  at  the  duodeno-jejunal  flexure,  and  so  would 
be  productive  of  the  state  of  affairs  usually  found  in  connection  with 
acute  gastric  dilatation  Added  to  these  causes,  which  might  be 
present  in  every  post-operative  case,  would  be  the  direct  interference 
with  the  viscera  in  abdominal  operations  of  all  kinds.  Especially 
would  this  be  the  case  in  operations  on  the  bile  passages,  where  the 
duodenum  and  small  intestines  are  constantly  pressed  by  gauze  pads 
out  of  their  normal  relations;  and  in  operations  for  the  removal  of  large 
ovarian  cysts  or  myomatous  uteres,  where  the  small  intestines  would 
naturally  fall  into  the  emptied  pelvis  and  occupy  a  position  which  in 
that  individual  patient  would  be  strange  and  unusual.  This  theory 
was  ably  supported  by  P.  Miiller  (1900).  Seelig  (1907)  suggested  that 
the  application  of  a  very  tight  abdominal  binder  might  favor  the  oc- 
currence of  acute  gastric  dilatation,  because  although  the  small  in- 
testines may  work  their  way  by  peristalsis  down  into  the  pelvis  under 
such  an  obstruction,  they  will  be  unable  to  get  back  again,  and  as  they 
accumulate  in  the  lower  abdomen  will  render  the  root  of  the  mesentery 
taut. 

Of  the  102  cases  analyzed  by  Conner,  42  (41  per  cent.)  followed 


ACUTE    DILATATION    OF    THE    STOMACH 


145 


operations  in  which  general  anesthesia  was  employed  (15  operations 
on  gall-bladder,  etc.;  17  after  other  abdominal  operations;  10  after 
operations  not  involving  the  abdomen) ;  other  cases  were  observed 
during  or  after  severe  diseases  (typhoid  fever,  pneumonia,  etc.);  others 
after  injuries;  others  after  indiscretions  in  diet;  six  were  associated 
with  disease  or  deformity  of  the  spine,  and  four  appeared  to  be  idio- 
pathic in  origin.  One  patient  with  typhoid  fever,  who  died  from  acute 
dilatation  of  the  stomach,  has  come  under  the  notice  of  one  of  us  (Ash- 
hurst)  at  the  Episcopal  Hospital,  in  the  service  of  Dr.  Charles  H.  Weber. 


Fig.  41. —  Campbell  Thompson's  Case  of  Acute  Dilatation  of  the  Stomach. 

Pathology. — The  stomach  is  found  to  fill  practically  the  whole 
abdomen.  Its  shape  is  characteristic,  presenting  usually  a  marked 
V-shaped  depression  in  the  lesser  curvature,  and  approximating  the 
form  found  in  gastroptosis,  especially  that  due  to  deformity 
from  tight  lacing,  though  very  much  more  pronounced.  As  pointed 
out  in  the  previous  paragraphs,  a  site  of  obstruction  has  most  fre- 
quently been  found  in  the  neighborhood  of  the  duodeno-jejunal  flexure, 
or  else  where  the  superior  mesenteric  artery  crosses  the  duodenum. 
Among  120  cases  which  came  to  autopsy,  Lafler  states  that  there  was 
obstruction  of  the  duodenum  by  the  root  of  the  mesentery  in  27.     The 

duodenum  as  far  as  the  point  of  constriction  is  frequently  much  dilated. 
10 


146  BEXIGX   DISEASES    OF   THE    STOMACH   AXD    DUODENUM 

There  is  rarely  any  obstruction  at  tlie  pylorus,  unless  it  is  manifestly 
due  to  a  kink  produced  by  the  descent  of  the  stomach.  The  fluid  con- 
tents of  the  stomach  are  due  to  hypersecretion,  as  well  as  to  mere  accu- 
mulation from  obstruction  of  its  outlets.  But  the  presence  of  the 
immense  quantities  of  gas.  and  its  rapid  re-accumulation  after  lavage  are 
not  so  easily  explained.  The  gas  is  no  doubt  in  large  part  due  to  fer- 
mentation, and  some  of  it  is  swallowed,  as  in  the  nervous  affection 
known  as  aerophagia.  But  to  account  for  the  re-accumulation  of  gas 
in  so  short  a  space  of  time,  some  authors  have  held  that  gas  was  pro- 
duced by  transudation  from  the  blood  vessels  in  the  stomach  walls. 
Whether  this  is  in  accord  with  modern  physiological  views  we  do  not 
know,  but  it  appears  to  be  a  far-fetched  explanation.  Gas-producing 
bacteria  have  been  found  in  the  stomach  contents,  according  to  some 
reports. 

There  is  as  a  rule  no  peritonitis;  and  the  site  of  operation,  if  an 
abdominal  operation  has  been  performed,  usually  presents  no  devia- 
tions from  the  normal.  Some  writers  have  confused  tympanitic 
distension  of  the  stomach  from  peritonitis,  with  acute  dilatation  of  the 
stomach.  In  the  former  condition,  which  is  by  no  means  so  rare  as 
acute  dilatation,  the  whole  intestinal  tract  may  be  much  dilated,  but 
the  stomach,  being  the  largest  hollow  organ,  is  apparently  dispropor- 
tionately dilated;  hence  the  confusion. 

Symptoms. — The  symptoms  of  this  malady  cannot  be  said  to 
be  always  very  distinct  or  readily  recognized.  Usually  the  onset 
is  sudden  in  character,  and  may  begin  from  twelve  to  twenty-four 
hours  after  the  operation,  although  in  many  instances  no  symptoms 
have  developed  until  convalescence  was  thought  to  be  assured.  The 
patient's  first  complaint  is  generally  discomfort,  referred  to  the  epi- 
gastrium, with  a  sense  of  distention.  Vomiting  occurs  promptly, 
wuth  comparatively  Httle  nausea;  and  large  amounts  of  dark  greenish 
fluid  are  gulped  up  without  straining.  The  vomitus  is  almost  never 
fecal,  and  is  seldom  very  offensive.  Bile  and  blood  may  be  present,  but 
usually  the  vomited  matters  are  composed  chiefly  of  gastric  secretion 
and  mucus,  and  present  a  characteristic  smell.  Vomiting  generally 
persists  to  the  end,  whether  this  be  the  death  or  the  recovery  of  the 
patient. 

The  distention  of  the  abdomen  may  be  readily  recognized  by  the 
eye,  being  most  prominent  to  the  left  of  the  median  Hne.  When  the 
stomach  tube  is  passed  there  is  an  abundant  escape  of  odorless  gas, 
with  a  gushing  or  a  gurgling  sound,  at  times  almost  an  explosion;  and  a 
marked  flattening  of  the  abdomen  usually  follows  evacuation  of  the 


ACUTE   DILATATION    OF    THE    STOMACH  1 47 

stomach  by  this  means.  But  within  a  very  short  time  after  the  stomach 
has  been  emptied  it  refills  again,  with  secretion  and  air,  and  the  patient's 
distress  is  as  great  as  ever.  It  is  extremely  rare  for  any  peristalsis  to  be 
observed.  Palpation  finds  the  abdominal  walls  not  rigid,  as  in  peri- 
tonitis, but  merely  tense  from  the  tension  within.  A  splashing  sound 
is  readily  obtained  from  the  stomach  contents,  and  is  usually  too  dis- 
tinct for  there  to  be  any  doubt  that  it  comes  from  an  air-containing 
cavity.  The  distention  of  the  stomach  is  extreme,  the  greater  curva- 
ture always  reaching  well  below  the  umbihcus,  and  frequently  extending 
to  the  pelvis.  Percussion  detects  a  tympanitic  note  over  the  most 
prominent  portion  of  the  distended  stomach,  and  the  usual  change 
of  level  in  the  dulness  produced  by  fluid  can  be  obtained  by  turning 
the  patient  to  one  side. 

Along  with  these  local  signs,  the  general  condition  of  the  patient 
is  seen  to  have  taken  a  sudden  turn  for  the  worse.  There  is  usually 
little  fever,  but  the  pulse  becomes  thready  and  rapid,  the  eyes  sunken 
and  bright,  the  tongue  heavily  coated,  the  breath  foul,  the  mind  de- 
lirious or  comatose,  and  dissolution  appears  imminent.  In  short  the 
evidences  of  toxemia  are  pronounced. 

In  milder  cases  of  the  same  nature,  the  stomach  is  reheved  by 
lavage  or  by  vomiting;  and  occasionally  a  profuse  diarrhea  is  the  first 
symptom  that  the  obstruction  has  been  overcome.  In  Roussel's 
patient  (1908)  there  were  from  25  to  35  extremely  offensive  movements 
daily.  It  is  much  better  to  remove  the  secretions  by  lavage,  since 
sometimes  fatal  absorption  from  the  small  intestines  will  kill  a  patient 
in  whom  the  subsidence  of  the  dilatation  of  the  stomach  and  the  evident 
onward  passage  of  its  contents  had  given  rise  to  hopes  of  recovery. 

Differential  Diagnosis.- — It  is  important  that  the  surgeon  should 
not  mistake  the  vomiting  caused  by  acute  dilatation  of  the  stomach 
for  that  due  to  the  anesthetic.  In  the  former  the  symptoms  usually 
do  not  arise  until  all  nausea  from  the  anesthetic  has  subsided;  but 
occasionally  when  the  post-operative  nausea  is  severe  and  long  con- 
tinued the  condition  may  pass  into  that  of  acute  gastric  dilatation 
without  any  pronounced  change  in  symptoms.  Peritonitis  is  frequently 
thought  of  when  the  symptoms  of  acute  gastric  dilatation  commence. 
The  period  of  onset  of  both  frequently  is  similar,  but  the  signs  are  not 
the  same.  Not  only  is  the  pain  of  a  different  character,  being  rather 
burning  than  sharp;  but  the  physical  evidences  of  a  large  amount  of 
fluid,  and  above  all  the  presence  of  the  succussion  splash,  will  at  once 
show  that  peritonitis  alone  is  not  the  condition  present.  Furthermore, 
the  evacuation  of  the  gas  and  other  stomach  contents  with  the  sub- 


148  BENIGN   DISEASES    OF    THE    STOMACH   AND   DUODENUM 

sidence  of  the  abdominal  distention,  which  follow  the  passage  of  the 
stomach  tube,  confirm  the  diagnosis,  and  usually,  for  a  time  at  least, 
produce  a  remission  of  symptoms.  Neither  peritonitis  nor  intestinal 
obstruction  will  be  so  affected.  Finally,  the  nature  of  the  preceding 
operation,  or  the  previous  course  of  the  disease  when  no  operation  has 
been  performed,  may  be  sufficient  to  exclude  both  peritonitis  and 
intestinal  obstruction.  Thus  operations  on  the  kidneys  or  the  extremi- 
ties, and  even  many  abdominal  operations,  such  as  those  for  the  radical 
cure  of  hernia,  could  under  no  normal  circumstances  be  productive  of 
peritonitis. 

Prognosis. — Among  the  217  cases  of  this  afi'ection  collected  by 
Laffer,  i ,^5  patients  died,  some  within  a  few  hours;  but  a  few  survived 
into  the  second  week.  One  lived  thirteen  days.  Seventy-seven  patients 
are  known  to  have  recovered;  and  in  5  the  result  is  not  recorded.  In 
Ruth's  more  recent  series  of  100  cases,  there  were  39  deaths.  Any 
disease  with  such  a  death  rate  must  be  considered  extremely  grave. 

Treatment. — As  in  other  affections  whose  pathology  is  not  well 
understood,  so  in  acute  dilatation  of  the  stomach,  treatment  must  be 
largely  empirical.  Lavage  of  the  stomach  is  the  first  indication.  As 
Terrier  (1905)  said,  it  is  only  a  matter  of  common  sense  to  empty  an 
over-distended  stomach. 

In  case  acute  dilatation  of  the  stomach  is  not  promptly  relieved  by 
the  first  lavage,  not  only  should  this  treatment  be  repeated  as  often 
as  indicated,  but  the  patient  should  be  made  to  lie  on  the  left  side, 
with  the  foot  of  the  bed  raised  so  as  to  bring  the  pelvis  higher  than 
the  diaphragm.  This  faihng  to  secure  relief,  the  belly  position  may 
be  tried,  the  patient  lying  prone  in  bed  after  the  stomach  has  been 
emptied  b.y  the  tube.  In  persistent  cases,  and  where  the  nature  of 
any  preceding  operation  does  not  contraindicate  it,  the  patient  should 
be  made  to  assume  the  kn^e-chest  posture  for  fifteen  minutes  out  of 
every  two  hours.  When  all  these  measures  prove  repeatedly  futile, 
the  abdomen  should  be  opened,  and  the  stomach,  if  still  distended, 
should  be  emptied  through  an  esophageal  tube.  If  now  a  kink  at  the 
pylorus  or  at  the  duodeno-jejunal  juncture  be  found  and  if  it  can  be 
relieved  without  further  interference,  the  surgeon  should  content 
himself  with  that;  but  in  most  of  the  reported  cases  it  has  been  evident 
that  no  such  simple  procedure  would  have  been  productive  of  benefit. 
The  surgeon  should  then  adopt  gastro-jejunostomy.  The  operation 
proposed  by  Robinson  (1900) — section  of  the  duodenum  and  its  re- 
union in  front  of  the  superior  mesenteric  vessels, — is.  as  said  by  Finney, 
a  thoroughly  unpractical  procedure. 


ACUTE    DILATATION    OF    THE    STOMACH  1 49 

Operative  treatment  of  acute  gastric  dilatation  appears  to  have  been 
adopted  in  about  32  cases;  among  this  number  to  which  we  have  ref- 
erences, there  were  17  deaths,  a  mortality  of  53  per  cent.  Nearly  all 
of  these  patients  had  been  subjected  to  non-operative  treatment  with- 
out success,  and  this  fact  should  be  remembered  in  comparing  the 
mortality  of  operative  treatment  with  that  of  medical  treatment. 
Moreover,  it  should  be  noted  that  whereas  only  2  out  of  14  operations 
(a  mortality  of  85.7  per  cent.)  recorded  in  the  first  edition  of  this 
work  proved  successful  in  saving  the  patients'  lives,  among  18  opera- 
tions since  recorded  13  proved  successful  (a  mortality  of  27. 7  per  cent.); 
showing  that  earlier  recognition  of  the  affection  and  more  efficient 
surgical  treatment  are  now  able  to  save  a  considerable  proportion  of 
patients. 

Among  the  cases  analyzed  by  Ruth,  the  gastric  tube,  with  or  with- 
out lavage  proved  successful  in  50  out  of  71  cases  in  which  this  method 
is  known  to  have  been  employed;  of  11  cases  in  which  the  stomach 
tube  is  known  not  to  have  been  used,  7  proved  fatal. 

Operations  for  Acute  Dilatation  op  the  Stomach 

I.  E.xploratory  Laparotomy.     13  cases  with  7  deaths;  mortality  53.8  per  cent. 
-Abdomen  closed  without  emptying  stomach: 

Jessop  (Lancet,  18S8,  i,  72(1).     Death. 

Robinson  (Cincinnati  Lancet  Clinic,  1900,  .xlv,  577).     Death. 
Stomach  emptied  itself: 

Lanphear  (cited  by  Ruth:  Am.  J.  Obst.,  igi3,  l.xviii,  525).     Rec. 

Templeton  (Cin.  Jour.,  1909,  xxiv,  3C2).     Rec. 
Stomach  emptied  by  tube  passed  through  esophagus; 

Littig  (cited  by  Ruth:  Am.  J.  Obst.,  1913,  Ixviii,  525)      Death. 

Macevitt  (N.  Y.  State  J.  of  Med.,  igo6,  vi,  284).     Rec. 

Moorhead  (J.  A.  M.  A.,  1909,  lii,  1909)      Rec. 

Turner    (Appendicitis,    Hernia,    and    Gastric    Ulcer.    London,    1905,    p.    113). 
Death. 
Adhesions  or  kinks  released: 

Axhausen  (cited  by  Ruth:  Am.  J.  Obst.,  1913,  Ixviii,  525).     Rec. 

Borchgrevink  (Surg.,  Gyn.  and  Obst.,  1913,  xvi,  662).     Death. 

Linke  (Beitr.  z.  khn.  Chir.,  1914,  xciii,  360).     Death. 

Petit  (These  de  Paris,  1900;  cited  by  Conner:  Am.  J.  Med.  Sc,    1907,  i,  345). 
Recovery  (after  jejunope.xy). 
Vohoilus  of  intestine  reduced,  dilatation  of  stomach  not  found  at  operation: 

Lichtenstein  (Zentr.  f.  Gyn.,  1906,  No.  44).     Death. 

II.  Gastrotomy.     8  cases  with  5  deaths. 

Appel  (Phila.  Med.  J.,  1899,  iv,  314).     Death. 

Box  and  Wallace  (Lancet,  1898,  i,  1538).     Death. 

Farquhar  (Brit.  Med.  J.,  igii,  i,  675).     Rec. 

Finney  (Bost.  Med.  and  Surg.  J.,  1907,  civ,  107).     Death. 

Hansen  (cited  by  Borchgrevnik:  Surg.,  Gyn.  and  Obst.,  1913,  xvi,  662).     Rec. 

Hoffman  (Miinch.  med.  Woch.,  1904,  li,  2003).     Death. 


150  BENIGN    DISEASES    OF    THE    STOMACH   AXD    DUODENUM 

!MacMonagle  (cited  by  Ruth:  Am.  J.  Obst.,  1913,  Ixviii,  525).     Recovery  after 

empt\-ing  stomach  through  trocar. 
Wright  (Practitioner,  1S97,  vi,  598.     Death. 

III.  Gastrostomy.     2  cases,  with  i  death. 

Brown  (Lancet,  1S99,  ii,   1017).     Death.     (Stomach  mistaken   for   pancreatic 

cyst.) 
Sommarin  (cited  by  Ruth:  Am.  J.  Obst.,  1913,  Lxviii,  525).     Rec. 

I\'.    Gastrojejunostomy.    9  cases  with  4  deaths. 

Baillet  (Bull.  Soc.  Chir.,  Paris,  1909,  xxv,  326).    Death. 
Lanz  (Nederl.  Tijdschr.  v.  Geneesk.,  1913,  Ivii,  279).    Rec. 
Lanz  (Ibid.).     Recov. 

Linke  (Beitr.  z.  klin.  Chir.,  1914,  xciii,  360).     Death. 
Linke  (Ibid.).     Recov. 

Kehr  (Arch.  f.  klin.  Chir.,  1897,  Iviii,  632).     Death. 
Korte  (Deutsch.  med.  Woch,  1904,  xxx,  1554).     Death. 
'        Stierlin  (Corresp.-Bl.  f.  Schweiz.  Aerzte,  1913,  xliii,  10S9).     Rec. 
Torrance  (N.  V.  iled.  J.,  1909,  lxx.\i.x,  70).     Rec. 

Atonic  Dilatation  of  the  stomach,  or  Gastric  Myasthenia,  though 
formerly  a  well  recognized  affection  of  the  stomach,  has  of  late  years 
become  a  disease  of  the  utmost  rarity.  This  is  largely  due  to  the 
increased  accuracy  in  diagnosis  of  gastric  affections  to  which  physi- 
cians have  attained,  but  in  no  small  measure  is  it  due  to  modern  surgery 
which  has  proved  by  the  living  pathology  of  the  operating  table  that 
most  of  the  cases  formerly  classed  as  atonic  dilatation  are  really 
examples  of  gastric  dilatation  due  to  well  defined  lesions,  chiefly  to 
pyloric  obstruction  from  carcinoma,  ulceration  or  perigastric  adhesions. 
There  is  no  doubt  that  after  such  debilitating  diseases  as  typhoid 
fever  the  gastric  walls  may  become  weakened,  and  become  readily 
subject  to  distention  and  dilatation  when  overloaded;  but  even  in 
cases  such  as  these,  there  is  no  good  reason  to  suppose  that  recovery, 
if  not  attained  by  medical  measures,  may  not  be  aided  by  operative 
means.  Long-standing  gastritis,  originally  catarrhal  in  form,  may 
eventually  invade  the  submucosa,  thickening  and  hardening  the 
gastric  walls,  and  thus  materiall}'  interfering  with  peristalsis.  In 
the  same  manner,  but  even  more  noticeably,  ulcerations,  cancerous 
growths,  and  even  the  ingestion  of  poisons,  may  greatly  impair  gastric 
motility  without  in  any  way  producing  stenosis  of  the  pylorus.  It 
is  not  impossible  that  the  gastric  nerves  may  be  the  seat  of  disease, 
without  there  being  any  change  in  the  gastric  wall  itself,  and  that  by 
this  means  dilatation  may  ensue  from  loss  of  motility.  But  such  a 
change  is  probably  much  rarer  than  it  has  heretofore  been  considered. 
Actual  degenerative  changes  (colloid,  fatty,  etc.)  in  the  muscle  fibres 
of  the  gastric  walls  are  probably  of  less  infrequent  occurrence. 


ATONIC   DILATATION"   OF    THE    STOMACH  151 

In  patients  with  this  form  of  gastric  dilatation,  the  absence  of 
distinct  history  is  the  chief  means  of  differentiating  the  disease 
from  that  form  due  to  pyloric  stenosis.  The  symptoms  from  which 
the  patient  seeks  relief  are  the  same  in  kind,  though  probably  less 
in  degree,  than  in  pyloric  stenosis.  The  sense  of  fullness  persist- 
ing from  one  meal  to  the  next,  the  anorexia,  the  thirst,  the  gaseous 
distention,  and  the  eructation — all  are  the  same  in  both  affections. 

Three  stages  of  gastric  myasthenia  may  be  recognized.  The 
first  is  the  stage  of  compensation,  the  second  that  of  stagnation, 
and  the  third  that  of  retention.  Early  in  the  disease  the  symptoms 
are  not  of  such  prominence  as  to  fix  themselves  in  the  patient's  mind; 
it  is  only  after  an  unusually  heavy  meal,  or  after  a  particularly  in- 
digestible one,  that  he  is  made  aware  of  his  dyspepsia.  The  gaseous 
distention  then  becomes  oppressive,  the  clothing  is  perhaps  uncon- 
sciously loosened,  and  relief  is  eventually  obtained  by  the  belching 
of  gas,  or  by  the  lazy  emptying  of  the  wearied  stomach  into  the  duo- 
denum. Not  unfrequently  a  little  sour  fluid  rises  into  the  mouth 
along  with  the  gas.  But  in  this  stage  compensation  is  generally 
sufficient,  and  these  periods  of  broken  compensation  arise  only  when 
some  unusual  strain  is  thrown  upon  the  stomach.  This  stage  may 
last  for  months  or  years;  but  it  is  exceedingly  prone  to  pass  into  the 
second  stage — that  of  gastric  stagnation,  a  condition  in  which  the 
stomach  is  unable  completely  to  evacuate  its  contents  between  meals, 
except  between  the  evening  meal  and  breakfast,  an  interval  sufliciently 
great  for  evacuation  to  be  accomplished.  The  patient  finds  it 
impossible  to  gain  in  weight,  though  it  is  not  usual  for  weight  to 
be  lost.  Digestion,  though  delayed,  is  eventually  completed.  When, 
however,  the  third  stage,  that  of  retention,  is  reached,  emaciation 
commences  and  may  become  extreme.  The  stomach  is  not  emptied 
even  during  the  night,  and  lavage  before  breakfast  will  detect  particles 
of  food  still  in  the  stomach;  and  the  gastric  contents  will  possess  the 
usual  characteristics  of  retention — they  will  be  sour,  rancid,  and 
usually  very  acid.  Occasionally,  when  atrophy  of  the  mucous  mem- 
brane is  present,  the  contents  are  neutral  or  alkaline  in  reaction. 
The  evidences  of  fermentation  are  pronounced,  and  the  production  of 
gas  will  continue  oftentimes  after  the  stomach  contents  have  been 
removed  by  lavage,  as  is  evidenced  by  the  separation  of  these  contents 
into  the  usual  three  layers.  The  dilated  stomach,  by  dragging  on  the 
pylorus,  causes  a  kinking  near  the  latter,  thus  adding  the  mechanical 
factor  of  actual  obstruction  to  the  myasthenia  which  was  the  primary 
cause  of  the  dilatation. 


152  BENIGN    DISEASES    OF    THE    STOMACH   AND    DUODENUM 

Secondary  nervous  symptoms  are  of  common  occurrence  in 
patients  suffering  from  gastric  retention  due  to  atonic  dilatation. 
The  source  of  these  symptoms  is  to  be  found  in  intestinal  toxemia. 
The  intestines  partake  of  the  atony  which  affects  the  stomach,  and  it 
is  precisely  because  there  is  no  pyloric  obstruction  that  the  fermenting 
gastric  contents  in  part  reach  the  small  bowels,  and  are  thence  ab- 
sorbed. Where  the  gastric  dilatation  is  due  merely  to  mechanical 
obstruction  at  the  pylorus,  this  obstruction  itself  protects  the  small 
bowels  from  the  decaying  food,  and  the  various  symptoms  of  hypo- 
chondriasis, hallucinations,  dyspnea,  tachycardia,  urticaria,  erythema 
fugax,  and  other  toxemic  affections  are  the  exception  rather  than  the 
rule. 

Treatment. — The  treatment  of  gastric  myasthenia  in  its  earlier 
stages  should  be  medical.  If  the  first  stage  be  recognized  it  often 
times  may  be  cured,  or  the  development  of  the  second  may  at  least 
be  indefinitely  postponed,  by  regulation  of  the  diet  and  tonic  treat- 
ment. During  the  second  stage,  in  addition  to  the  above,  lavage  is 
indicated;  and  electricity  may  be  employed  with  some  hope  of  benefit. 
But  when  once  the  stage  is  reached  where  weight  is  progressively  lost 
and  where  relative  pyloric  obstruction  is  present  (either  from  kinking 
or  from  relative  stenosis  of  this  orifice  of  the  stomach),  then  purely 
medical  measures  no  longer  will  be  found  efficient.  It  is  rarely  possible 
by  medical  means  even  to  keep  the  patient  from  losing  more  ground, 
let  alone  improving  him.  In  such  cases  as  these  we  think  operation 
should  be  undertaken,  provided  no  contraindication  to  any  operation 
exists;  but  the  patient  must  not  be  led  to  expect  an  immediate  cure. 
Probably  the  most  that  surgery  can  do  is  to  so  alter  the  mechanics 
of  the  stomach  and  intestines  that  medical  measures  will  become 
effective.  Hence  it  is  to  be  anticipated  that  a  prolonged  course  of 
medical  treatment  will  have  to  be  carried  out  after  the  operation  has 
been  performed. 

As  to  the  special  form  of  operation  to  be  employed,  it  has  long  been 
the  consensus  of  opinion  that  gastro-jejunostomy  is  the  best.  We  feel 
however,  that  surgeons  now  more  generally  adopt  Finney's  pyloro- 
plasty either  alone,  or  combined  with. some  form  of  gastroplication.  It 
is  difficult  to  decide  upon  the  respective  merits  of  these  two  methods, 
because,  as  already  remarked,  we  do  not  anticipate  the  phenomenally 
rapid  amelioration  of  symptoms  after  operation  for  this  condi- 
tion that  we  do  in  cases  of  pyloric  obstruction  without  marked  atony; 
and  too  many  medical  men  are  inclined  to  give  credit  for  the  slowly 
acquired   improvement   solely    to    the   medical   treatment   employed, 


SECONDARY   GASTRIC   DILATATION  1 53 

when  there  can  be  no  doubt,  at  least  so  it  seems  to  us,  that  without 
the  operation  which  improved  the  receptivity  of  the  gastro-intestinal 
tract,  food  and  drugs  would  have  been  of  as  little  avail  as  they  were 
before  the  patient  was  brought  to  the  surgeon .  While  our  own  preference 
in  the  past  has  been  for  gastro-jejunostomy  in  such  cases,  as  far  as  we 
can  judge  surgical  opinion  at  present,  it  is  in  favor  of  plastic  operations 
on  the  pylorus  for  these  patients,  and  is  opposed  to  gastro-jejunostomy 
for  any  but  obstructive  cases. 

Secondary  Gastric  Dilatation. — In  dealing  with  this  condition 
the  surgeon  must  never  lose  sight  of  t^ie  fact  that  it  is  not  a  distinct 
disease.  Ever  before  his  eyes  must  be  the  picture  of  a  stomach  that  has 
become  dilated  after  ineffectual  efforts  to  overcome  an  obstruction  to  its 
evacuation.  Only  in  this  way  will  he  be  able  to  appreciate  the  serious- 
ness of  that  stage  of  the  disease  at  which  his  unfortunate  patient  has 
arrived.  Were  medical  treatment  always  effectual  in  treating  the 
disease,  even  when  instituted  at  the  commencement  of  the  malady, 
the  surgeon  would  never  see  any  patients  with  gastric  dilatation.  It 
is  the  terminal  stage  of  a  serious  disease,  and  as  such  is  the  gravest  stage. 
The  patient  may  have  been  in  danger  from  hemorrhage  or  from  threat- 
ened perforation  at  earlier  periods  of  his  malady,  but  in  addition  to 
these  dangers,  which,  though  perhaps  less  imminent,  still  persist,  he  is 
now  affficted  with  the  most  serious  complication  of  all,  save  that  of 
carcinomatous  degeneration.  And  gastric  dilatation  due  to  benign 
obstruction  is  less  serious  than  gastric  carcinoma  only  because  patients 
with  the  forner  disease  die  more  slowly  than  do  those  with  cancer. 
Without  surgical  relief,  both  diseases  are  equally  fatal:  cancer  usually 
kills  in  a  shorter  time,  but  death  in  benign  gastric  dilatation  is  quite  as 
sure  even  if  longer  delayed. 

Causes. — Although  gastric  dilatation  in  the  immense  majority 
of  cases  is  caused  either  by  carcinoma  or  by  ulceration  about  the  pylorus, 
yet  in  exceptional  instances  other  factors  are  operative,  and  should 
therefore  be  borne  in  mind.  It  is  well  to  remember,  also,  that  changes 
in  the  duodenum,  similar  to  those  occurring  at  the  pylorus  itself,  are  not 
infrequently  productive  of  gastric  dilatation.  Especially  is  this  true 
of  ulceration  and  cicatrization  above  the  ampulla  of  Vater;  but  ulcers 
even  below  this  site,  as  well  as  other  affections  of  the  duodenum  similar 
to  those  implicating  the  pylorus,  may  also  cause  dilatation  of  the 
stomach. 

Systematic  writers  are  in  the  habit  of  classifying  the  causes  of 
obstruction  here,  as  elsewhere  in  the  alimentary  tract,  as  those  from 
changes  in  the  wall  of  the  pylorus,  those  within  the  lumen  of  the  canal. 


154  BENIGN   DISEASES   OF    THE    STOM.A.CH   AND   DUODENUM 

and  those  which  cause  obstruction  by  distortion  or  pressure  from  with- 
out. Among  the  changes  in  the  pyloric  wall  itself,  the  development 
of  carcinoma  probably  holds  first  place  in  the  production  of  gastric 
dilatation.  It  will  be  more  fully  considered  in  a  subsequent  chapter. 
Next  to  carcinoma,  pyloric  obstruction,  and  consequently  gastric 
dilatation,  is  most  frequently  due  to  hj'perplastic  or  cicatricial  changes 
produced  by  benign  ulceration.  As  will  be  presently  pointed  out,  a 
temporary  pyloric  obstruction  may  be  caused  by  hj-pcrplastic  ulcera- 
tion at  the  pylorus,  and  later  in  the  course  of  the  ulcer's  evolution  the 
hjperplasia  may  subside,  and  the  pylorus  again  become  patent  for  a 
short  time.  At  this  stage  the  symptoms  of  gastric  ulcer  may  tem- 
porarily disappear,  and  the  patient  may  consider  himself  cured.  At  a 
later  date,  however,  the  latent  ulcer  will  again  give  e\ddence  of  its 
existence,  when  by  its  cicatricial  contraction  the  pylorus  again  becomes 
obstructed,  this  time  permanently.  The  earlier  and  temporary  obstruc- 
tion usually  does  not  cause  gastric  dilatation;  it  is  rather  productive 
of  increased  peristalsis,  with  hypertrophy  of  the  muscular  walls,  and  is 
frequently  accompanied  by  pylorospasm,  gastrospasm,  and  peristaltic 
unrest  of  the  stomach  (see  p.  141). 

Apart  from  these  two  changes — carcinomatous  and  ulcerative — 
there  are  few  others  taking  place  within  the  walls  of  the  gastro-duodenal 
canal  which  are  ever  productive  of  secondary  dilatation  of  the  stomach. 
Yet  Moullin  (1907)  called  particular  attention  to  fibrosis  of  the  pylorus 
without  evidence  of  past  or  present  ulceration,  as  a  cause  of  stenosis; 
and  similar  cases  still  occasionally  come  under  the  surgeon's  care. 
Causes  of  obstruction  acting  from  within  the  gastro-duodenal  canal  are 
very  rarely  causes  of  gastric  dilatation.  The  pylorus  may  be  ob- 
structed by  foreign  bodies,  or  by  hair  balls,  or  b}'  concretions  due  to 
medicines  such  as  bismuth  administered  in  large  quantities  or  over  long 
periods  of  time;  but  it  is  extremely  unusual  for  such  agents  to  cause  any 
but  intermittent  obstruction  of  the  pylorus.  The  same  is  true  of  such 
pathological  changes  as  gastric  polypus  (see  p.  210).  Pylorospasm 
may  be  the  only  evidences  of  such  changes. 

But  the  agents  are  many  which  from  without  the  alimentary 
canal  may  cause  gastric  dilatation  by  means  of  pyloric  or  duodenal 
obstruction.  Not  only  may  adhesions  act  in  this  manner,  but  a  dis- 
tended gall  bladder,  or  a  large  biliary  or  pancreatic  calculus  may  similarly 
be  productive  of  dilatation  of  the  stomach.  The  senior  author  has  had 
a  number  of  cases  of  pyloric  and  duodenal  obstruction  with  secondary 
gastric  dilatation  following  the  removal  of  the  gall  bladder  due  to  ad- 
hesions either  of  the  pylorus  or  the  duodenum  to  the  site  of  removal  of 


SECONDARY   GASTRIC   DILATATION  1 55 

the  gall  bladder,  all  of  which  were  permanently  relieved  by  posterior 
gastroenterostomy.  To  prevent  such  adhesions  from  forming  after 
cholecystectomy,  not  only  should  the  gall-bladder  bed  be  most  care- 
fully repaired,  but  the  great  omentum  should  be  drawn  up  and  inter- 
posed between  the  liver  and  duodenum.  Chronic  pancreatitis  and 
cancer  of  the  head  of  the  pancreas  may  so  obstruct  the  duodenum  as  to 
cause  secondary  gastric  dilatation.  Enlarged  glands  in  the  portal 
fissure  of  the  liver,  or  along  the  common  bile-duct  as  well  as  retroperi- 
toneal tumors,  aneurisms,  etc.,  may  all  in  exceptional  cases  be  produc- 
tive of  secondary  gastric  dilatation.  Moreover,  in  addition  to  such 
causes,  the  displacements  of  the  various  abdominal  organs  may  even- 
tually lead  to  the  same  result.  The  influence  exerted  by  a  floating 
kidney  is  somewhat  hypothetical  in  this  respect;  but  there  is  no' doubt 
that  enlargement  of  a  fixed  right  kidney  may  cause  pyloric  obstruction^ 
and  there  is  good  evidence  for  believing  that  displacements  of  the  liver 
due  to  tight  lacing  or  other  causes  maybe  productive  of  dilatation  of  the 
stomach.  The  modus  operandi  of  the  change  in  the  latter  case  is  not 
always  easy  to  detect;  but  it  probably  is  either  by  directly  obstructing 
the  pylorus,  or  by  first  producing  gastroptosis,  which  in  turn  brings 
about  a  kinking  of  the  pylorus. 

Perigastric  adhesions — the  result  of  perigastritis,  as  the  condition 
was  called  when  it  was  considered  a  distinct  disease,  analogous  to  peri- 
typhlitis— are  due  to  a  variety  of  causes.  The  adhesions,  however, 
which  are  productive  of  gastric  dilatation  are  usually  to  be  traced 
to  affections  of  the  biliary  tract.  Indeed,  disease  of  the  biliary  tract 
is  in  many  instances  the  origin  of  the  whole  chain  of  gastric  disorders. 
This  connection  has  frequently  been  noted  (page  452).  In  a  smaller 
number  of  instances,  perigastric  adhesions  causing  pyloric  obstruction 
have  arisen  in  attacks  of  plastic  peritonitis  due  to  gastric  ulcers  them- 
selves; and  in  exceptional  cases  are  due  to  previous  attacks  of  periton- 
itis from  other  causes.  A  glance  at  Figure  42  (Andrews)  will  show 
how  disabling  these  adhesions  may  become. 

Chnical  Pathology. — The  changes  occurring  in  the  pylorus  and  the 
stomach  in  secondary  gastric  dilatation  are  reflected  with  fair  accuracy  in 
the  symptoms  which  are  observed.  In  the  early  stages  of  gastric  ulcera- 
tion there  frequently  occurs  such  hyperplastic  reaction  as  to  cause 
obstruction  of  the  pylorus,  if  not  to  produce  a  palpable  tumor.  Such 
inflammatory  masses  as  these,  producing  pyloric  obstruction,  and 
simulating  a  malignant  tumor,  have  on  several  occasions  (see  p.  263) 

'The  junior  author  had  such  a  patient,  with  pyonephrosis,  under  his  care  in  1914, 
in  the  Episcopal  Hospital. 


156 


BENIGN   DISEASES    OF   THE    STOMACH   AND   DUODENUM 


led  surgeons  to  the  performance  of  gastro-jejunostomy,  in  the  ex- 
pectation that  the  patient  would  thus  obtain  some  little  respite  from 
imminent  death.  In  such  cases  great  have  been  the  surprise  and  the 
joy  of  the  surgeon  and  the  patient  to  observe  after  a  few  months  that 
the  suspected  tumor  has  melted  away,  as  it  were,  the  relief  obtained 
by  means  of  the  operation  enabling  nature  to  produce  a  cure  of  the 
disease.     If  no  operation  had  been  performed  at  that  time,  onej^of 


Fig.   42. — Perigastric   Adhesions,   Involving   Gall-bladder,   Colon,   and   Sigmoid   Fle.\ure. 
The  Small  Intestine  has  been  Cut  Away.      {Avdre'ws.) 


three  courses  might  have  been  pursued  by  the  disease.  The  first 
and  most  usual  course,  we  think,  would  be  that  under  appropriate 
medical  treatment  sufiicient  rest  would  have  been  obtained  by  the 
inflamed  area  for  a  decrease  in  the  obstruction  to  have  occurred, 
with  a  subsidence  of  the  symptoms  of  peristaltic  unrest  of  the  stomach. 
This  would  be  only  a  temporary  lull,  however,  whereas  after  a  gastro- 
jejunostomy we  should  have  reason  to  expect  a  cure.  The  second 
course  might  have  been  for  the  obstruction  to  persist  and  to  lead 


SECONDARY   GASTRIC   DILATATION  157 

without  delay  to  gastric  dilatation;  while  the  third  course,  and  one 
which  we  are  satisfied  is  less  rare  than  that  just  mentioned,  would  be 
for  the  hyperplastic  area  to  undergo  malignant  change,  whether  or 
not  a  temporary  lull  occurred  in  the  evolution  of  the  disease  under 
medical  treatment. 

If  the  obstruction  of  the  pylorus,  due  to  the  hyperplastic  process, 
decreased  under  medical  treatment,  the  symptoms  would  naturally 
abate,  and  the  patient,  and  the  physician  as  well  would  naturally 
regard  the  disease  as  cured.  But  in  the  vast  majority  of  such  cases 
there  comes  a  time,  perhaps  months  or  even  years  later,  when  the 
gastric  ulcer  in  its  course  of  cicatrization  and  contraction  again  narrows 
the  pyloric  orifice,  and  when  the  old  stomach  symptoms  begin  afresh. 
It  is  at  this  stage  of  the  disease  that  secondary  dilatations  are  most 
frequently  seen. 

When  due  attention  is  paid  to  the  various  causes  of  pyloric  obstruc- 
tion, it  is  not  difficult  to  picture  the  course  which  the  disease  will 
pursue  in  each  individual  case.  As  a  rule,  a  temporary  gastric  hyper- 
trophy occurs,  with  increased  peristalsis,  and  for  a  time  the  obstacle' 
may  be  overcome.  Sooner  or  later,  however,  the  gastric  walls  yield, 
and  from  the  stage  of  compensation  that  of  stagnation  is  reached, 
and  this  finally  drifts  into  absolute  retention.  The  downhill  course 
is  most  rapid  in  maUgnant  pyloric  obstruction;  but  with  judicious 
medical  treatment  it  may,  in  patients  with  benign  obstruction,  extend 
over  a  period  of  years. 

Symptoms. — The  symptoms  of  secondary  dilatation  of  the  stomach 
are  usually  sufficiently  pronounced.  In  the  earlier  stages  of  the 
disease,  when  compensation  is  present,  or  even  later,  when  stagnation 
has  commenced,  the  symptoms  are  less  distinct;  but  when  once  reten- 
tion has  developed,  there  is  shght  probability  of  making  a  wrong 
diagnosis. 

The  subjective  symptoms  are  much  the  same  as  those  which  have 
already  been  described  under  atonic  dilatation  of  the  stomach.  But 
the  previous  clinical  history  of  the  patient  will  usually  throw  much  light 
upon  the  diagnosis.  Usually  the  patient  at  an  earlier  date  has  pre- 
sented symptoms  of  gastric  or  duodenal  ulcer;  and  possibly  there  has 
occurred  a  lull  in  the  evolution  of  the  disease,  when  the  ulcer  was  healing 
or  had  actually  healed,  and  before  it  had  contracted,  or  while  the  tone 
of  the  gastric  walls  was  still  sufficient  to  compensate  for  the  slight  ob- 
struction present.  After  this  temporary  abeyance  of  symptoms  there 
will  gradually  be  developed  the  sense  of  fullness  presisting  after  meals, 
perhaps  even  to  the  time  of  the  next  meal,  and  thus  leading  to  anorexia. 


158  BENIGN   DISEASES    OF   THE    STOMACH   AND    DUODENUM 

Because  fluids  are  not  absorbed  from  the  stomach,  and  because  in  the 
stages  of  stagnation  and  retention  they  are  late  in  reaching  the  small 
intestine,  if  they  reach  it  at  all,  there  is  more  or  less  constant  thirst.  As 
the  dilatation  progresses,  and  as  stagnation  becomes  extreme,  the 
dilating  stomach  occasionally  makes  the  attempt  to  empty  itself  by 
the  act  of  vomiting.  Generally  it  is  an  ineffectual  attempt,  some  of 
the  stomach  contents  not  being  expelled;  but  this  partial  evacuation 
procures  an  intermission  in  the  nausea  for  a  couple  of  days.  The  very 
fact  that  ingestion  of  food  does  not  always  provoke  emesis  shows  that 
the  ulceration  has  passed  the  irritable  stage;  and  the  copious  and  cumu- 
lative vomiting  which  recurs  every  second  or  third  or  fourth  day  is, 
in  itself,  very  good  evidence  that  the  stomach  is  dilated. 

To  these  usual  symptoms  should  be  added  one  less  usual,  but  of 
increasingly  frequent  occurrence  in  these  last  years,  when  the  pathology 
of  gastric  disorders  has  become  better  understood.  We  refer  to  gas- 
tric tetany,  which  may,  we  think,  be  most  appropriately  considered  as 
a  symptom  of  dilatation  of  the  stomach.  This  was  first  described  by 
Kussmaul  in  1869.  He  thought  it  was  caused  by  dehydration  of  the 
tissues,  due  to  the  pyloric  obstruction.  The  theory  of  autointo.xication, 
according  to  Fleig  (1908),  was  first  systematically  put  forward  in  1881 
by  Reuss.  But  to  this  theory  it  may  be  objected  that  autointo.xica- 
tion is  rare  without  intestinal  putrefaction,  and  that  in  most  cases  of 
gastric  tetany  there  is  no  evidence  of  intestinal  putrefaction,  the  py- 
lorus being  obstructed  and  preventing  the  discharge  of  gastric  contents 
into  the  intestinal  canal  whence  alone  they  may  be  absorbed.  We  are 
rather  inclined  to  assert  with  Fleig  that  autointoxication  can  at  most  be 
an  accessory,  but  not  the  main,  cause,  which  we  believe  is  dehydration 
of  the  tissues.  Possibly  as  Fleig  suggests  autointoxication  and  de- 
hydration may  alter  the  chemistry  of  the  thyroids  or  parathyroids. 
In  support  of  dehydration  as  a  cause,  Fleig  calls  attention  (i)  to  the 
numerous  case  reports  of  gastric  tetany  where  the  existence  of  dehydra- 
tion was  undeniable,  and  where  symptoms  were  relieved  by  the  intro- 
duction of  fluids;  (2)  to  the  occurrence  of  cramps  more  or  less  like  those 
of  tetany  in  many  diseases  where  dehydration  is  a  marked  feature,  such 
as  cholera,  typhoid  fever,  infantile  diarrhea,  etc.;  and  (3)  to  the  pro- 
duction of  cramps  in  the  lower  animals  by  artificial  concentration  of 
the  blood  by  means  of  intravaneous  injections  of  almost  any  hyper- 
tonic solution  (sodium  chloride,  glucose).  Cramps  may  even  follow 
the  polyuria  or  diarrhea  produced  by  diuretics  or  purges.  MacCallum 
and  his  associates  have  suggested  (1920)  that  deprivation  of  the  tissues 
of  chlorin,  owing  to  exclusion  from  the  intestinal  tract  of  the  hydro- 


GASTRIC    TETANY  159 

chloric  acid  of  the  gastric  juice,  may  be  the  cause  of  the  twitching  and 
convulsions.  They  point  out  that  there  develops  an  extreme  increase 
in  the  alkali  reserve  of  the  blood,  and  that  experimentally  such  symp- 
toms may  be  prevented  by  constantly  furnishing  a  large  supply  of  chlorids. 
The  cure  of  the  condition  they  found  by  no  means  so  easy. 

It  is  needless  to  dwell  here  upon  the  symptoms  of  tetany,  as  they 
are  detailed  in  every  text-book  of  medicine;  but  it  is  worth  while  noting 
that  certain  of  the  so-called  diagnostic  signs  may  be  absent.  Trous- 
seau's phenomenon  (production  of  typical  cramps  by  obstructing  the 
venous  circulation  of  the  arm)  was  absent  in  cases  reported  by  Albu, 
Ast,  and  Schlesinger.  Chvostek's  sign  (production  of  cramps  by  the 
lightest  tapping  of  the  motor  nerve  trunk,  especially  the  facial)  prob- 
ably is  more  constant.  Hoffman's  sign  (slight  pressure  over  sensory 
nerves  causing  paresthesia)  is  not  very  reliable.  Erb's  phenomenon 
(increase  of  galvanic  and  sometimes  of  faradic  excitabihty  of  all  nerves 
except  the  facial)  is  not  often  tested,  nor  is  Schlesinger's  phenomenon 
(painful  supination  of  feet  when  the  hip  is  flexed  while  the  knee  is  kept 
extended).  We  do  not  believe  that  it  is  necessary  for  the  surgeon  to 
delay  treatment  until  all  these  classical  signs  develop  in  full  intensity. 
In  mild  and  chronic  cases  this  may  be  possible,  but  as  ordinarily  seen 
the  condition  is  at  the  least  subacute  if  not  actually  acute  and  the 
patient  very  ill.  Under  such  circumstances  it  is  sufficient  for  the  surgeon 
to  find  a  patient  suffering  with  cramps  or  spasmodic  twitchings  in 
association  with  copious  vomiting,  suggestive  of  a  dilated  stomach,  for 
him  to  institute  active  treatment.  McKendrick  (1907)  referred  to  63 
cases  of  tetany  which  were  clearly  due  to  gastric  dilatation.  One  fatal 
case  of  gastric  tetany  following  gastro-jejunostomy  with  occlusion  of 
the  pylorus  has  come  under  the  notice  of  one  of  us  (Ashhurst) 

William  M.,  44  years  of  age,  was  admitted  to  the  Episcopal  Hospital  in  November,  igiSi 
complaining  of  vomiting  of  blood  and  pain  in  the  epigastrium.  Two  years  previously 
he  had  been  operated  on  by  another  surgeon,  gastro-jejunostomy  being  done  for  an  ulcer 
on  the  lesser  curvature  near  the  cardia;  there  had  been  no  pyloric  obstruction,  and  the 
pylorus  had  not  been  occluded  at  the  time  of  operation. 

Operation  by  Dr.  Ashhurst  (Nov.  9,  1015).  The  omentum  was  adherent  to  the  former 
incision.  The  pylorus  was  normal.  There  was  a  rrass  on  the  lesser  curvature  of  the 
stomach  extending  about  8  cm.  down  from  the  cardia.  There  were  enlarged,  hard,  dis- 
crete, lymph  nodes  in  the  gastro-hepatic  omentum.  The  anterior  wall  of  the  stomach 
was  opened  parallel  to  its  blood  vessels,  and  the  crater  of  a  callous  ulcer,  just  admitting  the 
finger  tip,  was  palpated  in  the  centre  of  the  indurated  area.  The  tumor  (presumably  be- 
nign) extended  so  far  toward  the  cardia  that  it  was  not  considered  safe  to  attempt  its 
excision.  The  old  gastro-jejunostomy  opening  would  not  admit  the  tip  of  the  finger  with- 
in the  stomach.  The  incision  in  the  stomach  was  then  closed,  and  the  great  omentum  and 
transverse  colon  delivered.  By  detaching  for  5  cm.  some  avascular  adhesions  between  the 
under  layer  of  the  mesocolon  and  the  jejunum  the  site  of  the  old  anastomosis  was  exposed. 


l6o  BENIGN   DISEASES    OF    THE    STOMACH    AND    DUODENUM 

and  it  was  now  found  permeable  to  the  finger.  To  enlarge  the  anastomosis  which  was  about 
3  cm.  in  diameter  the  posterior  gastric  wall  and  the  jejunum  were  incised  in  the  long 
axis  of  the  anastomosis  for  a  distance  of  5  cm.  each,  and  the  incision  was  reunited  trans- 
versely. Finally  the  pylorus  was  obstructed  by  a  linen  purse-string  suture  supplemented 
by  longitudinal  infolding  of  the  pyloric  canal.  It  was  hoped  these  measures  might  per- 
mit healing  of  the  ulcer. 

Nov.  15.  The  patient  has  done  well  and  today  was  given  soft  diet.  Later  he  vomited 
a  litre  or  more  of  fluid  all  at  one  time.  Liquid  diet  was  resumed  and  enteroclysis  of  glu- 
cose and  sodium  bicarbonate  solution  was  given. 

Nov.  17.  Slight  rise  of  temperature  (100.6°  F.).  Enteroclysis  retained.  Mind  not 
clear:  he  is  rather  noisy  and  cries  out  as  with  pain.  He  makes  peculiar  motions  with 
his  arms,  and  his  fingers  seem  rigid  and  partially  contracted.  The  condition  resembles 
the  beginning  of  a  spasm.     Only  cracked  ice  by  mouth. 

Nov.  20.  Better.  Liquid  diet  since  yesterday  without  vomiting.  Mind  is  not  quite 
clear  yet  and  tetany-like  movements  persist. 

Nov.  21.  Abdominal  incision  healed.  General  condition  better.  Pulse  averages  100, 
respirations  24,  and  temperature  remains  normal. 

Nov.  23.  Slightly  worse.  ^louthdry.  Still  twitching  of  muscles  and  irregular  move- 
ments of  extremities. 

Nov.  25.     Slowly  failing. 

Nov.  26.     Twitchings  still  present.     No  dilatation  of  stomach  can  be  detected. 

Nov.  27.  Noisy  and  restless.  Died  at  11  a.  m.,  eighteen  days  after  operation.  No 
autopsy  was  permitted. 

Bircher  (1911)  reported  one  case  of  gastric  tetan}-  which  followed  9  or 
10  days  after  gastro-jejunostomy  for  duodenal  ulcer.  In  neither  of  these 
cases  did  there  seem  much  doubt  that  the  condition  was  due  to  dehy- 
dration, from  copious  vomiting.  IMost  cases  on  record  have  not  fol- 
lowed any  operation,  but  have  arisen  in  patients  with  chronic  gastric 
dilatation  with  retention.  According  to  Bircher  the  mortality  of  the 
condition  under  medical  treatment  is  75  per  cent,  or  higher.  Kinni- 
cutt  (1909)  succeeded  in  controlling  the  spasms  by  intravenous  injec- 
tions of  soluble  calcium  salts  (usually  4  to  1000)  in  one  patient,  but 
death  eventually  occurred;  autopsy  by  Opie  showed  no  lesions  in  the 
parathyroids.  However,  in  three  of  Wirth's  collected  cases  the  para- 
thyroids were  found  at  autopsy  to  be  diseased.  According  to  Wirth's 
statistics  (1910)  operative  treatment  offers  much  better  chance  for 
recovery  than  does  non-operative.  He  collected  21  cases  of  operative 
treatment,  with  only  3  deaths  (15  per  cent,  mortality),  17  cures,  and 
one  patient  improved.  Bircher's  second  patient,  who  recovered  after 
gastro-jejunostomy,  is  not  included  in  Wirth's  figures.  Bircher  ad- 
vises for  the  worst  cases  that  only  jejunostomy  be  done,  as  the  simplest 
and  quickest  way  of  relieving  the  pyloric  obstruction;  in  others  a 
pyloroplasty'  or  gastro-jejunostomy  is  indicated. 

According  to  some  authorities.  Globus  Hystericus  is  frequently 
due  to  the  drag  on  the  esophagus  exerted  by  a  dilated  or  proptosed 
stomach. 


SECONDARY   GASTRIC    DILATATION  l6l 

The  objective  symptoms  of  secondary  gastric  dilatation  are  even 
more  characteristic  than  are  the  subjective.  The  capacity  of  the  stomach 
is  seen  to  be  increased,  not  only  from  the  excessive  amount  of  matter 
vomited,  but  from  the  amount  of  fluid  that  may  be  introduced  through 
the  stomach  tube.  Dilatation  of  the  stomach  with  air  will  also  make 
its  great  size  apparent.  In  men  the  dilatation  is  more  horizontal, 
while  in  women  the  increase  in  size  is  chiefly  toward  the  pelvis.  The 
level  of  the  greater  curvature  is  nearly  always  found  below  the  umbili- 
cus, and  in  women  it  not  infrequently  reaches  to  the  symphysis  pubis. 
The  dilatation  with  air  should  be  very  gradually  done  by  means  of  a 
hand  bulb  attached  to  the  stomach  tube.  The  stomach  should  mean- 
while be  lightly  percussed  and  the  sensations  of  the  patient  should  be 
the  infallible  guide  as  to  the  limit  of  distention  to  be  produced.  While 
in  most  cases  of  open  ulcer  we  think  even  the  passage  of  a  stomach 
tube  should  be  avoided  on  account  of  the  possibility  of  exciting  hem- 
orrhage or  producing  a  perforation,  in  secondary  dilatation  of  the 
stomach  we  think  no  damage  can  be  done,  provided  common  sense  is  ex- 
ercised and  the  manipulations  are  carried  out  with  gentleness  and 
patience.  Hurry  should  be  avoided  above  all  things;  it  is  under 
such  circumstances  the  equivalent  of  violence.  The  use  of  a  Seidlitz 
powder,  its  separate  parts  administered  at  short  intervals  one  after 
the  other,  may  be  more  agreeable  in  anticipation  to  the  patient,  but  it  is 
a  dangerous  and  uncontrollable  remedy,  and  as  such  should  be  avoided. 
It  is  impossible  to  determine  beforehand  either  the  force  of  the  effer- 
vescence or  the  capacity  of  the  stomach;  and  while  we  are  well  aware 
that  this  means  of  distention  has  been  employed  many  more  times 
safely  than  with  disaster  (see  p.  297)  yet  it  is  a  method  which  in  our 
opinion  is  barbaric  in  its  simpHcity.  The  outlines  of  the  stomach 
may  also  be  determined  by  means  of  skiagraphy,  after  the  administra- 
tion of  an  opaque  meal. 

The  examination  of  the  contents  of  the  stomach  reveals  the  usual 
fermentative  and  putrefactive  changes  of  gastric  retention.  The  fluid 
withdrawn  settles  into  three  layers — the  lowest  of  semi-solid  matter, 
the  middle  of  clear  or  slightly  cloudy  yellow  fluid,  while  the  topmost 
layer  is  extremely  frothy,  due  to  the  gas-producing  ferments  and 
micro-organisms. 

The  feces  of  the  normal  individual  contain  from  4  to  6  ounces 
of  solid  matter  in  twenty-four  hours,  and  about  75  per  cent,  of  water. 
As  a  result  of  the  lessened  absorption  which  occurs  in  gastric  dilatation, 
the  amount  of  solids  decreases  to  one  and  a  half  or  two  and  a  half 

ounces,  and  the  proportion  of  water  falls  as  low  as  40  or  even  30  per  cent. 

11 


l62  BEXIGN   DISEASES    OF   THE    STOM.\CH   AND    DUODENUM 

The  urine  is  also  much  diminished  in  quantity,  and  the  amount 
of  urea  and  chlorides  is  decreased. 

Diagnosis  and  Differential  Diagnosis. — As  has  already  been  men- 
tioned, extreme  degrees  of  gastric  dilatation  are  seldom  mistaken  for 
other  affections.  It  is  in  the  earh-  stages — those  of  compensation  and 
mild  stagnation — that  the  disease  is  most  frequently  overlooked. 
Such  patients  are  classed  as  dyspeptics,  and  are  treated  in  many  medical 
dispensaries  for  chronic  gastritis:  the  diagnosis  is  based  on  the  symptoms 
alone,  without  any  attempt  being  made  to  trace  the  evolution  of  the 
disease  or  to  apply  to  it  the  principles  of  physical  examination  of  the 
secretions,  and  their  digestive  power — methods  of  study  which  are 
nevertheless  constantly  employed  in  studj'ing  the  kidneys,  the  cardio- 
vascular system,  and  the  lungs.  It  is  in  these  early  stages  that  the 
pathologist's  findings  from  examination  of  the  gastric  contents  may 
give  the  iirst  clue  as  to  the  nature  of  the  disease.  But  it  is  only  a  clue, 
and  should  be  so  regarded.  Were  these  chronic  dyspeptics  studied  with 
the  care  their  sufferings  merit,  the  dispensaries  of  some  hospitals  would 
have  fewer  return  \isits,  but  more  patients  would  be  permanently 
cured  of  their  maladies  by  surgical  means,  before  their  strength  and 
\'italit3'  had  ebbed  so  low  that  scarcely  with  forced  feeding  and  stimula- 
tion will  many  of  them  be  brought  to  the  condition  where  they  may  be 
considered  good  operative  risks. 

When  the  early  stages  of  gastric  dilatation  are  once  recognized, 
it  next  becomes  important  to  determine  the  cause  of  the  dilatation; 
for  as  we  have  already  seen,  there  exist  two  distinct  groups  of  gastric 
dilatation,  the  atonic  and  the  obstructive.  The  former  is  rare,  and  it 
is  our  belief  that  it  grows  rarer  every  year,  as  more  patients  are  sub- 
jected to  operation,  and  as  the  surgeon  is  given  more  opportunities  to 
show  that  the  disease  is  really  of  an  obstructive  nature. 

With  due  attention  to  the  previous  historj'  of  the  patient  and 
strict  inquiry  into  the  cHnical  course  of  the  present  illness,  of  which 
illness  gastric  dilatation  is  a  stage,  it  will  in  most  instances  be  quite 
possible  to  draw  a  distinction  between  myasthenic  and  obstructive 
dilatation  of  the  stomach.  When  the  symptoms  of  gastric  dilata- 
tion appear  after  a  distinct  period  of  gastric  trouble,  whether  im- 
mediately or  remotely  preceding  the  present  symptoms,  obstruction 
is  almost  certainly  the  cause.  If  the  dilatation  has  developed  rapidly, 
in  the  course  of  a  few  weeks  or  months,  without  a  long  historj-  of  preced- 
ing-gastric indigestion,  especially  if  the  patient  be  past  early  adult  life, 
malignant  disease  is  probable.  When  no  preceding  indigestion,  typical 
of  gastric  or  duodenal  ulcer,  or  of  biUarj'  infection,  has  anno3'ed  the 


SECONDARY   GASTRIC   DILATATION  1 63 

patient  over  a  long  period  of  time — when,  in  short,  the  clinical  history 
is  negative — then  it  is  possible  that  we  have  to  do  with  a  case  of  myas- 
thenic dilatation.  A  point  in  the  differentiation  of  obstructive  from 
atonic  dilatation  of  the  stomach,  on  which  much  stress  has  been  laid 
by  Van  Valzah  and  Nisbet,  is  that  in  the  former  variety  of  dilatation 
solids  are  much  more  obstructed  than  are  liquids;  and  on  this  account 
toxemic  symptoms  are  less  usual  than  in  atonic  dilatation,  in  which 
latter  affection  the  fermenting  stomach  contents  every  now  and  again 
are  discharged  into  the  intestinal  canal,  whence  they  may  be  absorbed. 
In  obstructive  dilatation  fluids  are  evacuated  rapidly  compared  to 
the  rate  of  evacuation  of  solids,  so  long  as  the  stages  of  compensa- 
tion and  stagnation  persist;  and  Van  Valzah  and  Nisbet  claim  that 
in  this  disease  (obstructive  dilatation)  if  500  cc.  of  water  be  given  when 
the  stomach  is  empty,  it  will  be  evacuated  within  one  hour  and  a  half,  or 
long  before  the  atonic  (myasthenic)  stomach  "ceases  to  splash  or  to 
yield  water  upon  the  introduction  of  the  tube."  Atonic  dilatation, 
they  remark,  was  once  called  the  "  dyspepsia  of  liquids." 

In  myasthenia  pain  and  vomiting  are  exceptional;  in  obstruction 
pain  is  a  prominent  feature,  especially  when  perigastric  adhesions 
exist,  and  copious  vomiting  every  few  days  is  the  rule-  Finally, 
myasthenic  dilatation  is  usually  considerably  relieved  within  a 
reasonable  time  by  medical  treatment,  while  the  obstructive  form 
grows  progressively  worse,  even  when  such  treatment  is  instituted  in 
the  early  stages. 

Dilatation  of  the  stomach  must  not  be  confounded  with  a  simple 
large  stomach,  whether  it  be  congenitally  of  an  abnormally  large 
size,  or  due  to  long  continued  overfilling.  In  such  a  stomach  an 
attack  of  gastritis,  due  to  some  unusual  indiscretion  in  eating  or 
drinking,  may  simulate  for  a  time  gastric  dilatation.  But  the  in- 
flammation in  such  cases  is  quickly  relieved  by  functional  rest  and 
medical  treatment,  which  is  not  the  case  where  the  stomach  is 
dilated. 

Gastroptosis  is  another  affection  which  may  cause  rather  vague 
symptoms  of  indigestion.  But  the  surgeon  who  is  acute  in  eliciting 
a  patient's  clinical  history  will  not  easily  be  misled  into  mistaking 
gastric  dilatation  for  gastroptosis  or  vice  versa:  because  in  the  case 
of  obstructive  dilatation  it  is  exceedingly  rare  for  the  clinical  history 
to  be  negative;  while  in  uncomphcated  cases  of  gastroptosis  it  is  the 
rule.  In  uncomplicated  cases  of  gastroptosis,  we  say;  for  it  has  been 
our  experience  that  the  proptosed  stomach  is  always  dilated,  unless 
it  forms  a  part  of  a  general  visceroptosis. 


164  BEXIGX    DISEASES    OF    THE    STOMACH    AND    DUODENUM 

Prognosis. — In  secondary  gastric  dilatation  the  prognosis  is 
bad,  unless  the  mechanical  obstruction  be  relieved  by  mechanical 
means.  All  that  was  said  on  the  prognosis  of  gastric  ulcer  in  general, 
should  be  borne  in  mind  in  this  connection.  It  was  there  (p.  98) 
pointed  out  that  under  the  best  medical  treatment  the  death-rate 
from  gastric  ulcer  in  general  is  at  least  10  per  cent.,  with  a  large  propor- 
tion of  relapses;  but  that  after  timely  operation,  all  but  from  two  to 
five  per  cent,  of  the  patients  recover,  and  most  of  them  remain 
permanently  cured.  The  statistics  from  which  these  conclusions 
were  drawn  included  not  alone  cases  of  open  gastric  ulcer,  but  those 
cases  where  the  stomach  was  very  extensively  diseased — dilated, 
distorted,  or  contracted  as  a  result  of  chronic  ulceration.  We  possess, 
unfortunately,  no  series  of  statistics  by  which  we  can  compare  the 
results  in  patients  with  gastric  dilatation  who  have  been  treated 
medically,  with  those  obtained  in  the  same  class  of  patients  after 
operation.  The  large  masses  of  statistics  hitherto  published  include 
all  stages  of  gastric  ulcer;  and  it  is  only  because  gastric  dilatation  is  a 
more  serious  affection  than  gastric  ulcer  without  dilatation  that  con- 
clusions which  are  justly  drawn  from  statistics  of  the  disease  in  general, 
apply  with  greater  force  to  its  more  serious  aspects.  But  in  the  case 
of  gastric  tetany,  we  may  speak  in  figures  with  some  authority.  This 
affection  enjoys  a  mortality  under  medical  treatment  of  from  70  to 
80  per  cent.  Although  few  operations  so  far  have  been  done  for  its 
relief,  and  though  the  mortality  is  severe,  yet  when  compared  to  the 
figures  just  given  it  is  low.  Cunningham  (1904)  collected  8  operations 
for  gastric  tetany,  with  5  recoveries  and  3  deaths,  a  mortality  of  37.5 
per  cent.  To  these  ]\IcKendrick  (1907)  added  16  successful  cases, 
making  a  total  of  24  operations  with  only  3  deaths,  a  mortality  of  only 
12.5  per  cent.  In  the  three  fatal  cases  (reported  by  Fleiner  (2  cases), 
and  Gumprecht),  death  was  due  to  \'isceral  disease,  to  pneumonia, 
and  to  peritonitis. 

But  it  must  also  be  remembered  that  where  a  mechanical  obsta- 
cle exists  to  the  evacuation  of  the  stomach  it  will  be  only  a  question 
of  time  until  the  patient  starves  to  death  even  under  the  most  energetic 
medical  treatment.  The  starvation  is  slow,  and  it  is  barely  possible 
that  the  patient  will  not  recognize  the  fact  that  he  is  starving  to 
death;  but  the  intelligent  onlooker,  be  he  physician  or  layman, 
appreciates  the  true  seriousness  of  the  patient's  condition;  and  it  is  no 
longer  necessary  for  the  surgeon  to  urge  that  in  such  cases  surgery 
affords  the  only  escape  from  death.  What  the  surgeon  still  urges,  is 
that  the  operation  shall  be  undertaken  while  yet  there  is  sufficient 


GASTROPTOSIS  165 

recuperative  power  left  in  the  body  cells  of  the  wretched  patient. 
Perhaps  the  day  will  come,  but  it  has  not  yet  dawned,  when  the  sur- 
geon will  no  longer  need  to  urge  even  this,  but  when  all  physicians  will, 
as  at  the  present  time  the  most  progressive  of  them  do,  invite  the 
surgeon  to  see  their  stomach  cases  with  them,  in  order  that  they  may 
decide,  in  the  light  of  the  knowledge  the  physician  can  shed  on  the 
case,  not  only  whether  an  operation  is  required,  but  also  at  what 
period  of  the  disease  it  had  best  be  undertaken.  We  have  no  hesita- 
tion whatever  in  saying  that  when  obstructive  dilatation  of  the  stomach 
is  once  diagnosed,  all  delay  should  be  avoided,  and  surgery  should  at 
once  remedy  the  mechanical  defect  which  Nature  and  her  handmaid 
Medicine  are  unable  to  remove. 

Treatment. — The  choice  of  operation  lies  between  gastro-jejunos- 
tomy,  pylorectomy,  and  pyloroplasty.  Unless  suspicion  of  malignancy 
is  entertained,  we  think  pylorectomy  for  gastric  dilatation  is  to  be 
condemned.  As  a  rule,  patients  with  severe  grades  of  gastric  dilata- 
tion are  not  good  surgical  risks,  so  that  pylorectomy  often  is  unjusti- 
fiably severe;  for  the  same  reason  we  should  propose  e.xcision  only  in 
an  extremely  small  number  of  these  cases.  We  believe  that  gastro- 
jejunostomy will  continue  to  give  in  the  future,  as  it  has  in  the  past, 
the  best  results;  and  that  Finney's  operation  should  be  reserved  for 
those  patients  in  whom  gastric  motility  is  but  slightly  impaired.  This 
would  limit  its  application  to  gastric  dilatation  to  the  earliest  stages 
of  the  disease.  It  is  certain,  moreover,  that  gastro-jejunostomy  gives 
more  immediately  gratifying  results  in  patients  whose  pylorus  is 
almost  impassable  even  to  liquids;  so  that  in  the  earlier  stages  of 
dilatation,  where  the  pylorus  is  still  slightly  patent,  Finney's  operation 
may  be  preferred. 

Gastroptosis 

Gastroptosis,  a  condition  in  which  the  whole  stomach  is  displaced 
downward,  sometimes  requires  surgical  treatment.  The  causesj^of 
the  affection  are  obscure.  Glenard,  in  1885,  drew  attention  to  general 
visceral  prolapse  involving,  besides  the  stomach,  the  intestines,  usually 
the  right  kidney,  and  sometimes  the  liver  and  spleen  as  well.  To 
account  for  these  changes,  various  theories,  none  of  them  very  satis- 
factory, have  been  advanced.  Only  a  few  etiological  factors  seem  to  be 
susceptible  of  demonstration.  It  is  a  condition  which  is  very  much 
more  frequent  in  females,  and  good  reasons  exist  why  this  should  be  so. 
Apart  from  the  influence  of  the  clothing  of  that  sex,  including  the  use  of 
corsets,  the  practice  of  tight  lacing,  and  of  suspending  heavy  skirts  from 


1 66 


BENIGN  DISEASES   OF   THE   STOMACH  AND   DUODENUM 


the  waist  instead  of  from  the  shoulders  or  hips,  there  are  the  well  known 
influences  of  repeated  pregnancies  and  childbirths  in  relaxing  the  ab- 
dominal walls  and  weakening  the  pelvic  floor.  All  these  mechanical 
factors  tend  to  allow  a  descent  of  the  structures  in  the  upper  abdomen. 
Scoliosis,  and  other  deformities  of  the  skeleton  which  reduce  the  area 


Fig.  43. — Various  Degrees  of  Gastroptosis. 


of  the  upper  abdominal  regions,  are  also  considered  by  some  to  be  causes 
of  gastroptosis.  Sudden  loss  of  flesh,  as  in  wasting  diseases,  such  as 
typhoid  fever  and  severe  attacks  of  influenza,  is  thought,  and  sometimes 
with  apparent  good  reason,  to  be  a  cause  of  gastroptosis.  The  in- 
fluence which  a  dilated  stomach  exerts,  both  by  its  weight  and  its 
atony,  has  been  too  little  appreciated;  and  when  once  gastroptosis  is 


GASTROPTOSIS  I 67 

added  to  dilatation,  food  stagnation  is  mechanically  favored,  and  one 
condition  continues  to  aggravate  the  other.  A  floating  kidney,  which 
by  its  weight  displaces  the  duodenum  and  transverse  colon,  is  a  well 
recognized  factor  in  the  development  of  gastroptosis. 

The  clinical  pathology  of  gastroptosis  is  of  some  importance.  We 
may  recognize  three  groups  (Fig.  43).  (i)  Where  the  greater  curvature 
of  the  stomach  is  still  above  the  umbiHcus;  (2)  where  the  lesser  curva- 
ture is  still  above,  though  the  greater  has  descended  below  the  navel; 
and  (3)  where  even  the  lesser  curvature  has  passed  below  the  umbiUcus. 
The  stomach  is  usually  dilated;  among  32  cases  of  gastroptosis  studied 
by  Worden  (1906)  there  were  only  3  in  which  the  stomach  was  not 
dilated.  The  gastro-hepatic  and  gastro-phrenic  omenta  are  stretched, 
as  is  the  transverse  meso-colon;  the  transverse  colon  sags  and  the 
stomach  becomes  more  or  less  horizontal,  lying  in  the  transverse  rather 
than  in  the  longitudinal  axis  of  the  body;  and  in  extreme  cases  the 
pylorus  itself  descends,  dragging  the  first  and  second  portions  of  the 
duodenum  with  it.  The  transverse  duodenum  is  usually  so  securely 
fixed  that  its  position  does  not  change,  but  sometimes  it  is  found  lower 
than  normal,  crossing  the  fourth,  or  fifth,  instead  of  the  third,  lumbar 
vertebra.  These  changes  naturally  are  prone  to  cause  a  kinking  of  the 
pylorus,  and  will  add  to  the  gastric  dilatation  usually  present. 

Symptoms  are  occasionally  absent  in  cases  of  gastroptosis,  even 
when  the  displacement  is  well  marked.  In  other  patients  a  very  slight 
degree  of  gastroptosis  causes  very  distressing  and  disabling  symptoms. 
Those  of  neurasthenia  are  frequently  more  pronounced  than  the 
symptoms  referable  to  the  stomach  itself.  In  general  the  symptoms 
resemble  those  of  dilated  stomach.  There  is  flatulence  after  eating, 
occasionally  so  pronounced  as  to  constitute  peristaltic  unrest  of  the 
stomach.  The  clothes  are  loosened  and  in  severe  cases  the  reclining 
position  is  habitually  assumed  after  meals.  Large  meals  are  avoided; 
and  so  painful  may  the  process  of  digestion  become  that  patients  will 
almost  starve  themselves  rather  than  endure  it.  Emaciation  is  the 
usual  sequel.  The  pain  is  a  tearing  or  a  stretching  sensation,  as  a  rule 
easily  cUstinguishable  from  the  intense  boring  pain  of  gastric  ulceror 
cancer. 

From  symptoms  alone  it  is  rarely  possible  to  reach  an  accurate 
diagnosis.  Physical  examination  is  much  more  satisfactory.  In- 
spection of  the  abdomen,  with  the  patient  standing,  usually  reveals 
a  protruding  lower  abdomen,  not  due  to  fat,  for  these  patients  are 
usually  emaciated,  but  to  the  descent  of  the  stomach  from  the  epigas- 


t68  benign  diseases  of  the  stomach  and  duodenum 

trie  to  the  umbilical  or  hypogastric  regions.  The  epigastrium  is 
empt)'  and  hollow,  and  frequently  the  pulsations  of  the  aorta  are  visible 
below  the  ensiform  process.  On  palpation  this  pulsation  can  almost 
always  be  felt  with  abnormal  distinctness.  The  contour  of  the  lower 
chest,  showing  the  effects  of  corset  pressure,  is  of  diagnostic  value. 
Some  authors  have  insisted  upon  the  mobility  of  the  tenth  rib,  as  a 
predisposing  cause,  allowing  undue  pressure  upon  the  liver,  and  through 
it  displacing  the  stomach.  Palpation  and  percussion,  especially  when 
the  stomach  has  been  distended  with  air  or  fluid,  will  readily  enable  the 
examiner  to  outline  the  greater  curvature,  and  in  severe  cases  the  lesser 
curvature  also  may  be  detected  in  this  manner.  Skiagraphy 
may  be  emploj^ed  though  we  incline  to  the  opinion  that  a  correct 
diagnosis  may  almost  always  be  made  without  it;  and  it  is  possible 
that  in  some  cases  the  weight  of  the  bismuth  or  barium  meal  may  cause 
the  appearance  of  ptosis  when  none  is  present. 

Treatment. — As  it  is  becoming  more  and  more  fully  appreciated 
that  gastroptosis  is  not  an  isolated  condition,  but  almost  invariably 
a  part  of  a  general  visceroptosis,  it  is  no  longer  the  custom  to  limit 
surgical  treatment  to  the  stomach  alone.  The  condition  often  verges 
into  that  broad  and  rather  hazy  field  of  intestinal  stasis;  but  in  these 
pages  no  attempt  will  be  made  to  discuss  this  vexed  question.  It  is 
merely  desired  to  call  renewed  attention  to  the  fact  that  non-operative 
measures  frequently  are  effectual  and  always  should  be  tried  before 
opening  the  abdomen.  Especially  valuable  is  forced  feeding,  the 
patient  being  confined  to  bed  for  several  weeks,  with  the  foot  of  the 
bed  elevated  to  overcome  the  effect  of  gravity.  General  and  abdom- 
inal massage  should  be  given.  These  measures  almost  always  will 
cause  a  deposit  of  fat  in  the  mesenteries  and  omenta,  which  will  give 
sufficient  support  to  the  fallen  viscera  to  overcome  the  distressing 
symptoms.  When  sufficient  weight  has  been  put  on,  the  patient 
may  be  allowed  to  sit  up  for  a  short  time  each  day,  and  may  gradually 
(very  gradually)  resume  active  life.  Elevation  of  the  foot  of  the  bed 
and  careful  dieting  (forced  feeding,  not  abstinence  from  food)  should 
be  continued  for  many  weeks  after  presumed  convalescence.  A 
properly  fitting  orthopedic  corset,  which  supports  the  lower  abdominal 
wall  while  leaving  the  upper  abdomen  and  lower  thorax  free,  should 
be  worn  constantly  when  out  of  bed.  Such  a  support  should  be  shown 
by  fluoroscopy  to  hold  the  viscera  in  proper  position. 

Operative  treatment  is  rarely  called  for  in  cases  of  gastroptosis. 
Various  methods  of  operating  have  been  adopted.  Gastroplication, 
proposed  as  a  remedy  for  dilated  stomach  in  1891  by  Bircher,  was 
first  employed  by  Summers  in  1897  in  a  case  of  gastroptosis.     It  was 


GASTROPTOSIS  I 69 

adopted  also,  with  success,  by  Hodge  (1906)  in  combination  with 
Beyea's  method  of  gastropexy  to  be  presently  described. 

Duret,  in  1896,  was  the  first  to  resort  to  operation  for  the  relief 
of  gastroptosis.  He  did  a  gastropexy,  suturing  the  anterior  gastric 
wall  to  the  parietal  peritoneum.  Rovsing  and  Hartmann  employed 
similar  operations.  Beyea  in  1899  described  a  second  method  of 
operating  by  gastropexy  which  he  had  practised  first  in  1897;  he 
shortened  the  gastro-hepatic  omentum  by  a  series  of  interrupted 
sutures.  About  the  same  time,  according  to  Blecher  (1900),  Bier 
devised  and  employed  a  similar  operation,  though  an  account  of  his 
method  was  not  published  until  later.  Coffey  (1902)  sutured  the 
root  of  the  great  omentum  to  the  abdominal  wall,  thus  giving  support 
to  the  stomach  from  below.  Gastro-jejunostomy  has  also  been 
employed  by  a  number  of  surgeons;  it  was  particularly  supported  by 
Hammer  (1903),  who  came  to  the  conclusion,  both  from  a  review  of 
the  literature,  and  from  his  own  experience,  that  it  was  preferable 
to  any  other  operation.  Such  was  formerly  our  own  opinion;  we  had 
found  no  cases  of  gastroptosis  unaccompanied  by  gastrectasis,  and 
although  the  relief  of  symptoms  following  gastro-jejunostomy  under 
such  circumstances  has  not  been  so  pronounced  or  so  constant  as  in 
patients  with  dilatation  of  the  stomach  without  gastroptosis,  yet  it 
was  satisfactory  both  to  patient  and  surgeon.  It  is  undeniable,  how- 
ever, that  the  profession  as  a  whole  does  not  regard  gastro-jejunostomy 
as  the  best  form  of  operation  for  gastroptosis.  This  is  so,  we  believe, 
because  it  is  becoming  more  and  more  recognized  that  the  ptosis  of 
the  stomach  is  not  the  only,  even  if  the  most  conspicuous  lesion;  it 
is  but  a  part  of  a  general  visceroptosis,  accompanied  by  intestinal 
stasis,  which  usually  requires  more  extensive  operative  interference, 
if  the  patients'  symptoms  cannot  be  relieved  by  non-operative 
methods. 

The  theoretical  objections  to  gastropexy  by  Buret's  method  are 
the  interference  with  the  motility  of  the  stomach  and  the  liabiUty  of 
the  newly  formed  adhesions  to  cause  more  discomfort  than  the  original 
disease.  But  Rovsing,  according  to  Coffey  (191 2),  has  reported 
163  cases  treated  by  this  method,  with  92  complete  cures  (over  56  per 
cent.),  34  greatly  improved,  17  sUghtly  improved,  24  unimproved 
(under  15  per  cent.),  and  only  8  deaths.  From  these  particular 
theoretical  objections  to  Duret 's  method,  the  operation  of  Beyea  is 
free,  since  the  stomach  is  raised  approximately  to  its  normal  position 
by  shortening  the  gastro-hepatic  omentum,  without  the  formation 
of  adhesions  to  the  stomach  itself.     Beyea  stated  (1913)  that  he  had 


170  BENIGN  DISEASES   OF  THE   STOMACH  AND   DUODENUM 

resorted  to  this  operation  in  43  patients,  40  of  whom  were  traced: 
23  were  classed  as  cured  (53.5  per  cent.),  14  as  improved  (32.5  per 
cent.),  and  only  3  were  not  improved. 

Omentopexy. — Coflfey  reported  in  191 2  the  end  results  in  40  patients 
with  gastro-intestinal  stasis  (due  to  causes  other  than  stricture  or  ulcer) 
who  had  been  treated  by  his  "hammock  operation"  of  omentopexy. 
These  were  mostly  cases  of  enteroptosis.  He  obtained  26  sympto- 
matic cures  (65  per  cent.);  9  great  improvements  (22.5  per  cent.); 
4  slight  improvements  (10  per  cent.) ;  and  only  one  failure.  This 
patient  had  tuberculous  ulcers  of  the  intestines.  We  beheve,  with 
Coffey,  that  in  many  cases  a  combination  of  operative  measures  will 
bring  the  best  results;  Coffey  recommends:  first,  shortening  of  the 
natural  supports  of  the  liver  and  stomach  by  the  method  of  Beyea; 
second,  suture  of  the  great  omentum  (just  below  the  transverse  colon) 
to  the  abdominal  wall,  above  the  umbihcus,  with  sutures  which  pass 
entirely  through  the  omentum;  third,  expand  the  upper  abdomen 
and  contract  the  lower  by  plastic  operations  on  the  abdominal  walls. 
Coffey  correctly  insists  that  these  methods  are  to  be  employed  only 
when  non-operative  measures  have  been  faithfully  tried  without 
relief. 

Douglas  (191 5)  traced  eight  out  of  ten  patients  who  had  been 
operated  on  by  a  combination  of  Coffey's  and  Beyea's  methods: 
7  showed  marked  improvement,  and  i  was  not  benefited  although 
weight  had  been  gained.  X-ray  examinations  showed  the  stomachs 
usually  in  a  lower  position  than  soon  after  the  operations,  but  in  no 
cases  as  low  as  before  operation. 

In  all  cases  treated  by  operation,  the  same  careful  attention  to 
methods  of  increasing  the  deposit  of  fat  in  the  mesenteries  and  omenta, 
and  proper  support  of  the  abdominal  walls,  should  be  adopted,  after 
operation,  as  advised  in  speaking  of  non-operative  treatment. 


CHAPTER  VI 

OBSTRUCTION  OF  THE  CARDIAC  ORIFICE  OF  THE 

STOMACH 

Congenital  Imperforation  of  the  Esophagus.^ — Although  this 
affection  is  extremely  rare,  and  is  seen  rather  by  the  pediatrist  than 
the  general  surgeon,  yet  it  seems  worthy  of  short  notice  in  this  chapter, 
inasmuch  as  gastrostomy  or  some  similar  operation  presents  the  only 
hope  of  cure. 

The  subject  was  well  reviewed  by  Demoulin  (1904)  and  by  Zeit 
(191 2),  the  latter  of  whom  succeeded  in  collecting  fifty-five  recorded 
cases.  The  gastric  portion  of  the  esophagus  communicated  with  the 
trachea  in  44  of  50  cases  studied  by  Demoulin,  and  with  the  bronchi 
in  2  cases.  It  is  therefore  extremely  unusual  for  the  malformation  to 
consist  of  a  simple  obstruction  of  the  lumen  of  the  esophagus  by  a 
membrane,  or  even  for  the  two  portions  of  the  esophagus  to  lie  in  the 
same  axis,  connected  by  a  fibrous  band.  The  symptoms,  which  exist 
from  the  time  the  child  begins  to  take  nourishment,  consist  (i)  in  the 
constant  and  persistent  regurgitation  of  food,  and  (2)  in  the  recurrent 
attacks  of  smothering  which  are  recognized  as  characteristic  of  the 
disease.  These  smotherings  are  due  to  the  regurgitation  of  mucous  and 
gastric  juice  into  the  air  passages,  through  the  gastric  portion  of 
the  esophagus.  If  the  baby  does  not  die  of  asphyxia  in  one  of  these 
attacks,  pneumonia  may  occur  from  the  regurgitation  of  gastric 
fluids,  or  from  the  inspiration  of  food.  Inanition  will  quickly  kill  the 
infant  should  he  escape  all  other  perils. 

Operative  treatment,  according  to  Demoulin,  was  first  sug- 
gested in  1866  by  Tarnier,  who  proposed  gastrostomy.  Steel  (1888) 
was  the  first  to  perform  gastrostomy.  His  patient  was  twenty- 
four  hours  old,  and  died  in  twenty- four  hours.  In  1903  Robineau 
again  operated,  on  the  third  day  of  life,  by  gastrostomy;  but  his 
patient  died  on  the  third  day.  Villemin's  case,  reported  by  DemouKn, 
was  operated  on  in  1904,  at  the  age  of  three  days,  by  gastrostomy; 
this  patient  lived  five  days  after  the  operation.  Kirmisson  (1904) 
reported  the  fourth  fatal  case,  operated  on  at  the  age  of  three  days 

171 


172        OBSTRUCTION    OF    THE    CARDIAC    ORIFICE    OF    THE    STOMACH 

by  gastrostomy.  Putnam  (1906)  has  added  a  ftfth  fatal  case,  and  Bren- 
nerman  (1913)  two  other  cases  of  operation  (jejunostomy  in  one, 
gastrostomy  in  the  other),  both  unsuccessful. 

The  question  naturally  arises,  in  view  of  the  extent  of  the  malforma- 
tion, whether  any  operation  can  be  expected  to  be  of  benefit.  Broca 
has  expressed  himself  as  unalterably  opposed  to  any  operation  on  an 
infant  so  malformed. 

In  discussing  Demoulin's  paper,  Broca  gave  as  his  opinion  that 
death  is  the  best  solution  of  the  difficulty;  that  he  had  been  gratified 
to  learn  that  all  the  patients  operated  on  had  died;  and  that  on  this 
account  he  was  glad  to  study  with  Demoulin  new  and  more  complicated 
operations,  because  these  will  be  still  more  certain  to  result  in  death. 
Never,  he  said  in  conclusion,  would  he  assume  the  responsibility  of 
putting  into  circulation  in  the  world  an  infant  with  its  mouth  in  the 
duodenum!  To  our  mind,  such  an  infant  is  no  more  of  a  monstrosity 
than  one  whose  alimentary  tract  empties  into  the  bladder,  or  possesses 
no  opening  at  all  at  its  lower  extremity;  and  we  fail  to  see  why,  if 
operation  be  justifiable  in  one  case,  it  will  not  be  equally  so  in  the  other. 
The  surgeon  is  not  an  executioner.  It  is  not  for  him  to  decide  whether 
an  individual  is  fit  to  live  or  not.  His  duty  is  to  prolong  his  patient's 
life,  and  to  use  the  agencies  of  modern  surgery  in  the  attempt  to  overcome 
deformities  and  to  restore  the  malformed  to  a  state  as  nearly  normal 
as  possible.  It  may  be  objected  to  this  reasoning  that  a  patient  who 
already  has  a  malformation  of  his  esophagus  is  rendered  only  more 
abnormal  by  the  formation  of  a  gastric  fistula.  Such  a  reply,  we 
submit,  is  not  argument,  it  is  repartee.  But  it  may  be  further  argued, 
that  even  were  the  patient  who  has  submitted  to  gastrostomy  to  sur- 
vive the  perils  of  infancy — that  even  were  he  to  reach  an  age  when  a 
more  serious  operation  might  justifiabh'  be  undertaken — it  might 
be  said  that  even  at  that  period  of  his  fife  surgery  could  oft'er  no  perma- 
nent solution  of  the  difficulty;  in  other  words  that  the  restoration  of  an 
esophagus  whose  upper  end  is  a  blind  pouch,  and  whose  lower  end 
opens  into  the  trachea,  is  a  problem  beyond  the  possibility  of  solution 
by  surgery.  For  our  own  part,  we  do  not  take  so  narrow  a  view  of  the 
surgical  possibilities  of  the  future.  We  have,  on  the  contrary,  the 
utmost  confidence  that  all  problems  of  mere  technique  will  ultimately 
be  solved.  We  cannot,  of  course,  hope  to  make  a  new  esophagus 
grow;  but  given  the  patient,  fit  for  an  operation  for  the  restoration  of 
such  an  esophagus,  and  we  doubt  not  that  some  surgeon  will  solve  the 
problem  of  the  technique.  It  may  not  be  in  Broca's  time,  nor  even 
during  our  own  lives;  but  we  are  none  the  less  confident  that  such 


CARDIOSPASM  173 

a  time  will  come.^  We  therefore  give  it  as  our  unqualitied  opinion 
that,  save  in  the  already  moribund,  the  surgeon  is  not  only  justified 
in  resorting  to  operation,  but  he  would  be  worthy  of  condemnation 
should  he  refuse  to  employ  the  skill  he  possesses  in  the  attempt  to 
give  these  patients  a  fighting  chance  for  life. 

Gastrostomy  has  heretofore  been  the  only  operation  employed. 
On  account  of  the  danger  of  liquids,  injected  into  the  stomach  by  the 
gastric  fistula,  entering  the  lungs  by  way  of  the  esophageal  communi- 
cation, Demoulin  suggested  that  jejunostomy  would  be  a  safer  operation. 
If  this  could  be  safely  combined  with  ligation  of  the  pylorus,  and  gastros- 
tomy as  well,  a  state  of  affairs  temporarily  satisfactory  might  be  obtained . 
If  the  pylorus  were  not  Hgated,  bile  and  pancreatic  juice,  and  possibly 
also  the  injected  food  stuffs,  might  find  their  way  into  the  stomach; 
and  unless  the  stomach,  even  when  excluded  from  the  digestive  tract, 
as  by  ligation  of  the  pylorus,  were  drained  exteriorly,  it  would  still 
discharge  its  secretions  into  the  trachea,  and  so  threaten  death  from 
suffocation.  Possibly  gastro-jejunostomy  combined  with  gastros- 
tomy, by  passing  a  tube  through  the  gastrostomy  wound  and  the 
gastro-jejunostomy  into  the  jejunum  (the  method  of  Rutkowski  and 
Witzel)  might  accomplish  the  same  result.  But  any  operation  on 
infants  a  day  or  so  of  age  must  be  simple  and  quick;  and  for  these 
reasons  we  prefer  gastrostomy.  Roux's  method  of  subcutaneous 
gastro-esophageal  anastomosis  or  one  of  its  modifications  (p.  322)  will 
afford  the  patient  a  chance  for  ultimate  cure,  should  immediate  death 
be  averted. 

Cardiospasm;  Diffuse  Dilatation  of  the  Esophagus. — This  is  not 
an  affection  of  great  rarity.  Plummer  (191 2)  has  had  130  cases  under 
his  personal  observation. 

Its  pathogenesis  is  obscure.  It  was  formerly  held  that  it  was 
strictly  analogous  to  pylorospasm;  but  this  is  merely  begging  the 
question,  as  the  pathogenesis  of  the  latter  is  also  obscure.  Most 
authorities  at  present  believe  that  there  is  some  disturbance  of  in- 
nervation of  the  esophagus  or  of  the  cardia;  very  few  cases  are  due  to 
actual  lesion  (ulcer,  stricture)  at  the  cardia  (12  out  of  Plummer's  130 
cases  had  such  lesions).     A  polyp  was  the  cause  in  a  case  reported  by 

'  The  above  paragraphs  were  written  before  the  publication  (January,  1907)  of  the 
daring  operation  by  which  Roux  of  Lausanne  seeks  to  form  a  new  esophagus  by  trans- 
planting beneath  the  skin  of  the  sternum  a  coil  of  the  jejunum  excluded  from  the  intestinal 
tract;  and  also  before  the  appearance  of  Baudouin's  article  (1907),  where,  being  ignorant 
of  Roux's  operation,  he  proposed  to  connect  an  esophagostomy  opening  in  the  neck,  with  a 
gastrostomy  opening  in  the  epigastrium,  by  means  of  a  rubber  tube,  or  some  similar 
contrivance.     (See  page  322.) 


174        OBSTRUCTION    OF   THE    CARDIAC    ORIFICE    OF    THE    STOMACH 

Ledderhose  (1904).  Bassler  (1914)  believes  that  the  trouble  is  not 
in  the  esophagus  or  cardia  at  all,  but  consists  in  a  spastic  contraction 
of  the  esophageal  opening  in  the  diaphragm,  producing  obstruction 
above  the  cardia. 

Symptoms. — ]Mild  cases  often  pass  unperceived.  The  patient 
may  feel  that  the  food  lodges  a  moment  before  entering  the  stomach, 
and  may  be  able  to  force  it  through  voluntarily,  by  taking  a  long 
breath  and  contracting  certain  of  the  pharyngeal  and  esophageal 
muscles.  Such  patients  as  these  usually  are  neurotic  or  hysterical 
females;  24  of  Plummer's  cases  were  of  this  type,  and  in  none  was  there 
diffuse  dilatation  of  the  esophagus.  In  more  severe  cases,  usually 
patients  without  a  neurotic  taint,  a  pouch  develops;  the  patient,  eating 
little  at  a  time,  will  form  a  habit  of  retiring  to  a  quiet  nook  after  taking 
food,  and  will  there  wrestle  with  the  obstruction  until  either  it  gives 
way  or  the  distress  is  relieved  by  vomiting.  In  these  cases  no  anatomic 
stenosis  is  found;  of  Plummer's  cases,  91  were  of  this  type.  Passage 
of  a  bougie  in  such  cases  usually  detects  both  the  obstruction  and  the 
pouch.  The  diagnosis  is  aided  by  direct  esophagoscopy  and  by  X-ray 
examinations. 

Treatment. — In  the  hands  of  an  expert  the  best  treatment  is 
divulsion  of  the  obstructing  area  by  means  of  some  form  of  baloon 
dilator  passed  down  the  esophagus.  This  was  adopted  by  Russell 
in  1898,  Rosenheim  in  1902,  and  has  been  extensively  employed  by 
Plummer  since  1906.  Taking  the  largest  class  of  cases,  those  patients 
with  diffuse  dilatation  of  the  esophagus,  without  anatomic  stenosis, 
in  Plummer's  series,  91  in  number,  it  is  interesting  to  learn  that  he 
had  knowledge  of  the  end  results  in  84  cases;  3  patients  could  not  be 
traced,  3  had  died  of  intercurrent  affections  since  operation,  and  i 
died  as  a  result  of  the  operation,  from  rupture  of  the  esophagus  (pres- 
sure of  720  mm.  of  mercury,  but  without  pain  during  application  of 
this  pressure) ;  73  patients  were  found  to  be  completely  cured  from  i 
to  6  years  after  operation,  and  11  were  not  completely  cured,  still 
presenting  annoying  sjonptoms,  which  however,  might  probably  be 
relieved  by  further  divulsion.  Two  or  three  divulsions  are  given  at 
intervals  of  a  few  days;  then  if  no  food  residue  is  found  in  the  esophagus 
after  a  ten  day  interval  without  treatment,  the  patient  is  dismissed 
until  further  s}Tiiptoms  arise.  Plummer  considers  a  pressure  of  575 
mm.  of  mercury  relatively  safe;  but  absence  of  pain  is  not  a  safe  indica- 
tion of  the  amount  of  pressure  permissible. 

Divulsion  of  the  cardia  after  gastrotomy  has  been  employed 
occasionally  in  these  cases  for  over  a  generation.     The  late  Prof. 


CARDIOSPASM 


175 


Ashhurst,  in  1893,  referred  to  cases  of  this  kind  in  the  hands  of  Loreta, 
V.  Bergmann,  Catani,  Frattini,  and  Billroth.  Mikulicz  reported  six 
such  operations,  no  recurrence  of  the  trouble  being  noted  in  any  case. 
Ledderhose's  patient,  already  referred  to,  recovered  after  removal  of  a 
polyp  from  the  lower  end  of  the  esophagus.  Other  cases  of  direct 
divulsion  of  the  cardia  after  gastrotomy  have  been  recorded  by  Erd- 
man  (1906),  and  E.  Martin  (1906);  both  patients  obtained  permanent 
relief  of  symptoms.  After  opening  the  anterior  wall  of  the  stomach 
the   cardia   is   divulsed   digitally    (Mikulicz   employed   forceps    with 


Pig.  44. — -Exposure  of  Cardia  after  Left  Lateral  Ligament  of  Liver  has  been  Divided 
and  the  Liver  Drawn  to  the  Right,  i,  la.  Cut  edges  of  Left  Lateral  ligament;  2,  Lower 
End  of  Esophagus;  3,  Non-peritoneal  Surface  of  Diaphragm;  4,  Re-entrant  Angle  be- 
tween Liver  and  Diaphragm;  5,  Non-peritonearSurface  of  Liver.  {Lambert,  in  Surgery, 
Gynecology  and  Obstetrics.)^ , , 

rubber  covered  blades)  until  two  or  even  three  lingers  will  readily 
enter  the  esophagus.  The  stomach  is  then  closed,  replaced,  and  the 
abdominal  wound  repaired  without  drainage. 

Cardioplasty,  analogous  to  the  pyloroplasty  of  Heineke-Mikuhcz, 
was  employed  by  Wendel  (1910).  The  cardia  was  exposed  by  tempo- 
rary resection  of  the  left  costal  border;  the  artery  crossing  the  cardia 
was  doubly  ligated  and  divided ;  and  the  esophagus  was  drawn  down 
into  the  abdomen  far  enough  to  be  temporarily  ligated  with  tape 
above  the  cardia.  The  stomach  was  then  clamped,  and  a  longitudinal 
incision  made  through  the  lowest  part  of  the  esophagus  through  the 


176        OBSTRUCTION    OF   THE    CARDIAC    ORIFICE    OF    THE    STOMACH 

cardia  into  the  stomach.  This  incision  was  then  closed  transversely; 
the  diaphragm  was  stitched  to  the  newly  formed  cardia,  and  the  opera- 
tive field  covered  by  suturing  the  stomach  around  it  to  the  diaphragm. 
A  gastric  fistula  was  formed  for  temporary  feeding.  Recovery  was 
prompt  and  permanent.  Lambert  (1914)  employed  a  similar  opera- 
tion, obtaining  good  exposure  of  the  cardiac  orihce  by  detaching  the 
left  lateral  ligament  of  the  liver  (Figs.  44,  45);  he  introduced  (through 
a  gastrostomy,  opening)  a  clamp,  to  act  on  the  principle  of  Dupuytren's 
enterotome,  one  blade  being  placed  each  side  of  the  contracted  cardia, 


Fig.  45. — Exposure  of  Cardia  and  Esophagus,  i.  Cut  Edge  of  Left  Lateral  Ligament 
of  Liver;  2,  Dilated  Lower  End  of  Esophagus,  Drawn  Through  Diaphragmatic  Opening;  3, 
^\Tiich  has  been  Incised;  4,  Re-entrant  Angle  between  Liver  and  Diaphragm.  (Lam- 
bert, in  Surgery.  Gynecology  and  Obstetrics.) 

and  the  clamp  being  gradually  tightened  until  it  cut  through  the  walls 
of  the  esophageal  pouch  and  the  fundus  of  the  stomach.  His  patient 
recovered  excellent  health. 

Willy  Meyer  (1911  and  1912)  obtained  a  cure  in  three  cases  of 
cardiospasm  by  plication  of  the  dilated  esophagus  by  means  of  thora- 
cotomy. He  w-as  inclined  to  believe,  however,  that  the  most  valuable 
part  of  the  procedure  was  the  separation  of  the  vagi  from  the  esophagus, 
and  that  the  plication  may  have  been  unnecessary. 

Cicatricial  Contraction  of  the  Cardiac  Orifice  of  the  Stomach,  from 
other  than  malignant  disease,  is  so  extremely  rare  that  it  need  only  be 


CICATRICIAL    OBSTRUCTION  177 

mentioned  in  passing.  When,  as  is  less  infrequently  the  case,  it  is 
caused  by  the  ingestion  of  corrosive  liquids,  the  symptoms  are  over- 
shadowed by  those  of  esophageal  stricture,  but  when  this  tube  is  not 
involved,  the  usual  symptoms  of  cardiac  obstruction  are  present,  but 
without  the  cachexia  which  so  early  develops  in  cancer.  If  bougies 
(which  should  be  passed  only  under  the  control  of  direct  vision,  through 
an  esophagoscope)  fail  to  keep  the  passage  open,  internal  esophago- 
tomy  (by  direct  esophagoscopy)  may  be  attempted;  but  divulsion,  as 
recommended  for  cardiospasm,  is  too  unsafe  for  cicatricial  contraction. 
Or  gastrostomy  may  be  done,  and  the  cardia  may  be  cautiously  dilated 
instrumentally  or  by  the  fingers,  and  retrograde  passage  of  a  bougie 
attempted.  Much  good  may  ensue,  as  in  stricture  of  the  esophagus, 
from  attaching  a  string  to  the  bougie,  and  drawing  it  out  of  the  mouth. 
The  stricture  may  then  be  sawed  by  means  of  the  string,  whose  two 
ends,  passing  from  the  mouth  and  the  gastrostomy  wound,  may  be  tied 
together  and  thus  kept  safely  in  place.  Or  gradually  increasing  sizes 
of  rubber  tubing  may  be  drawn  through  the  stricture  by  means  of  the 
string.  It  is  well  in  any  case  to  keep  the  gastric  fistula  patulous  for  a 
number  of  months;  it  may  be  used  from  time  to  time  while  some  passing 
irritation  of  the  cardia  is  subsiding,  and  until  nourishment  may  be 
taken  again  in  the  usual  wav. 


CHAPTER  VII 
HOUR-GLASS  STOMACH  AND  GASTRIC  DIVERTICULA 

Hour-glass  Stomach. — This  term  well  describes  the  condition 
found  in  the  immense  majority  of  patients  in  whom  the  stomach  is 
loculated;  but  as  cases  are  occasionally  observed  in  which  three  (Moyni- 
han,  Paterson,  Kausch,  Schmitt)  and  even  five  pouches  (Klein)  e^dst, 
the  term  segmented  stomach,  advocated  by  Wolfler  (1895),  is  more 
generally  applicable.  And  as  diverticula  of  the  stomach  are  produced 
by  essentially  the  same  causes  as  those  operative  in  cases  of  hour-glass 
contraction,  it  is  convenient  to  consider  them  both  in  the  same  chapter. 

The  condition,  first  noted  by  Amyand  (1734),  was  subsequently  de- 
scribed by  Morgagni  (1761).  The  earlier  writers  on  the  subject,  and 
those  even  until  recent  years,  considered  it  a  congenital  anomaly 
in  the  vast  majority  of  cases.  Later  writers,  notably  Moynihan, 
have  proved  that  as  a  congenital  deformity  it  is  of  the  utmost  rarity, 
if  indeed  not  altogether  unknown.  Moynihan  is  not  willing  to  accept 
as  genuine  examples  of  congenital  deformity  any  of  the  cases  whose 
records  he  has  examined,  nor  has  his  study  of  museum  specimens 
altered  his  opinion.  Delamare  and  Dieulafe  recorded  in  1906  the  case 
of  a  bilocular  stomach  in  a  new  born  baby,  born  of  syphilitic  parents, 
but  with  no  syphihtic  lesions  itself;  in  this  case  the  only  lesion  found, 
even  on  microscopical  examination,  consisted  in  hypertrophy  of  the 
muscular  coat  at  the  junction  of  the  cardiac  and  the  pre-pyloric  por- 
tions. Gardiner  (1907)  observed  hour-glass  contraction  of  the  stomach, 
associated  with  an  accessory  pancreas,  at  autopsy  on  a  child  three 
months  old.  It  must  further  be  remarked  that  as  recent  anatomo- 
physiological  researches  have  called  renewed  attention  to  the  stomach, 
we  realize  the  truthfulness,  heretofore  almost  forgotten,  of  the  descrip- 
tions of  normal  stomachs  long  ago  made  by  Home,  Cruveilhier,  Henle, 
and  others;  and  we  are  thus  able  to  explain  as  normal  many  appear- 
ances found  post-mortem  which  were  at  one  time  considered  patholog- 
ical (see  Chap.  II,  p.  46).  Moreover,  even  in  cases  of  hour-glass 
stomach  observed  in  infants  and  young  children,  it  may  be  quite  possible 
for  the  deformity  to  be  explained  as  due  to  pre-existent  disease  of  the 
stomach  in  infantile  or  intrauterine  life. 

178 


CLINICAL  PATHOLOGY  179 

While,  therefore,  it  cannot  be  categorically  denied  that  such  a 
thing  as  a  congenital  hour-glass  stomach  may  occur,  it  must  be  ac- 
knowledged to  be  of  extreme  rarity;  and  any  cases  reported  as  such 
deserve  prolonged  and  critical  investigation. 

Schomerus  (1904)  found  that  among  1014  operations  for  gastric  le- 
sions, 71  or  7  per  cent,  were  for  hour-glass  stomach.  Among  154 
operations  for  hour-glass  stomach  which  he  studied,  128  were  in  females 
and  26  in  males.  The  chief  cause  of  acquired  hour-glass  contraction 
is  preceding  gastric  ulcer,  but  some  cases  are  due  to  cancer,  usually  to 
that  form  which  has  developed  as  a  consequence  of  benign  ulceration; 
others  are  caused  by  pressure  of  neighboring  organs,  as  corset  liver 
Rasmussen  (1887),  according  to  Schomerus,  thought  that  hour-glass 
stomach  might  be  caused  by  pressure  0/  the  left  costal  border;  some  cases 
are  caused  by  perigastric  adhesions;  and  a  few  are  produced  by  the 
ingestion  of  corrosive  liquids,  as  in  a  case  recorded  by  Klein,  in  which 
operation  was  done  by  Schnitzler  (1900).  Other  cases  of  hour-glass 
stomach,  due  to  the  ingestion  of  acids,  have  been  recorded  by  Carle, 
Gersuny,  Hacker,  and  Korte.  Syphilitic  ulceration  is  a  rare  cause 
(Guillemot,  1899).  Langenbuch  recorded  a  case  accompanied  by 
tuberculous  ulceration  in  both  pouches;  but  the  etiological  relation  of  the 
ulcers  was  doubtful. 

Clinical  Pathology. — The  constriction  is  usually  single,  situated 
somewhat  nearer  the  pyloric  than  the  cardiac  orifice,  and  the  greater 
curvature  is  more  often  drawn  up  toward  the  lesser,  than  the  reverse. 
But  while  these  are  the  usual  characteristics,  a  great  variety  of  deformi- 
ties has  been  encountered.  In  the  cases  studied  by  Schomerus  the 
constriction  was  near  the  pylorus  in  51,  midway  between  the  orifices  in 
34,  and  near  the  cardia  in  only  13  patients. 

When  the  pjdoric  pouch  is  large  there  are  two  dangers — the  first 
and  more  common  is  that  at  operation  the  cardiac  pouch  may  be 
entirely  overlooked,  and  a  gastro-enterostomy  done  with  the  pyloric 
portion,  without  improving  the  patient's  condition.  This  error, 
according  to  Lieblein  and  Hilgenreiner  (1905),  has  been  made  by 
Bier,  Czerny,  Kuster,  Hartmann,  and  others.  All  the  known  cases 
have  been  attended  by  a  fatal  result.  The  other  danger  is  that  an 
unusually  large  pyloric  pouch  may  be  the  seat  of  volvulus,  as  in  cases 
recorded  by  Langerhans,  Doyen,  and  others,  the  greater  curvature 
ascending  toward  the  left,  and  adding  the  factor  of  strangulation  to  the 
pre-existent  obstruction.  Volvulus  of  a  large  cardiac  pouch  does  not 
appear  to  have  been  observed. 

The    frequency    with    which    pyloric    stenosis    complicates    hour- 


l8o  HOUR-GLASS   STOMACH    AND    GASTRIC   Dn'ERTICULA 

glass  Stomach  has  been  much  emphasized  by  Robson  and  Moynihan. 
The  stenosis  in  both  situations  maybe  due  to  ulcer,  or  one  maybe  caused 
by  perigastric  adhesions  These  adhesions  may  act  as  a  bridle,  passing 
across  the  stomach  from  one  curvature  to  the  other,  or  the  stomach- 
may  itself  become  adherent  to  the  neighboring  organs  or  to  the  anterior 
abdominal  wall.  In  one  case  of  trifid  stomach,  recorded  by  Robson 
and  Moynihan.  both  constrictions  were  due  to  ulceration;  in  their 
second  patient  one  constriction  was  caused  by  ulcer,  the  other  by  ad- 
hesions. Dilatation  of  the  duodenum  should  not  be  mistaken  for  hour- 
glass stomach.  Christian  (1907)  has  recorded  an  interesting  case  in 
which  such  an  error  was  made. 


Fig.  46. — Hour-glass  Stomach  from  Carcinomatous  "Saddle"  Ulcer  on  Lesser  Curvature 
with  Perforation.      From  a  Patient  in  the  Episcopal  Hospital.      (Half  Natural  Size.) 

.  A  saddle  ulcer  on  the  lesser  curvature  is  a  frequent  cause  of  hour- 
glass stomach.  In  a  case  reported  by  the  junior  author  (1Q02)  this  ulcer 
showed  beginning  carcinomatous  change  (Fig.  46).  The  condition  in 
one  patient  at  the  Lankenau  Hospital  where  the  contraction  was  formed 
by  extensive  perigastric  adhesions  is  shown  in  Fig.  47. 

In  the  majority  of  patients  under  our  care,  however,  the  constric- 
tion has  been  due  to  cicatrization  of  benign  ulcers.  In  one  patient 
the  lesion  was  thought  at  operation  to  be  malignant;  but  as  the  patient 
remained  in  good  health  more  than  four  years  after  the  operation  (gas- 
tro-gastrostomy  and  Finney's  pjdoroplasty)  it  is  evident  that  the  clinical 
diagnosis  was  erroneous. 

The  symptoms  of  hour-glass  stomach  are  rarely  distinguishable  from 
those  due  to  inloric  obstruction  caused  bv  ulcer.     If  the  constriction 


PHYSICAL    SIGNS 


I8l 


is  close  to  the  cardia,  the  cliaical  picture  simulates  obstruction  of  this 
orifice.  In  most  of  the  recorded  cases  the  condition  has  been  found  at 
autopsy,  or  has  been  met  with  unexpectedly  at  an  operation  for  the 
rehef  of  long-standing  gastric  symptoms  usually  thought  to  have  been 
caused  by  ulceration  at  the  pylorus. 

Hour-glass  constriction  is  one  of  the  latest  results  of  gastric  ul- 
ceration. Frequently  no  history  of  acute  ulceration  can  be  discovered;, 
and  it  is  almost  always  certain  that  the  condition  when  met  with  at 
operation  has  existed  for  many  years. 


//  ■ 


Fig.  47-- 


-Hour-glass  Stomach  from  Perigastric  Adhesions  (Gastric  Ulcer), 
in  the  Lankenau  Hospital.      (Half  Natural  Size.) 


From  a  Patient 


By  physical  examination  it  is  sometimes  possible  to  make  a  positive 
diagnosis  before  opening  the  abdomen.  Moynihan  in  his  first  six 
cases  made  a  correct  diagnosis  only  once  before  operation;  among  his 
next  nine  patients,  however,  he  made  the  diagnosis  in  seven  with  reason- 
able certainty  before  operation.  The  detection  of  hour-glass  contrac- 
tion by  physical  examination  depends  largely  upon  the  use  of  the  stomach 
tube  or  skiagraphy.  On  filling  the  stomach  with  liquid  through  the 
tube.  V.  EiscLsberg  noticed  that  a  prominence  appeared  first  in  the  left 
hypochondrium,  and  that  a  few  seconds  later  this  swelling  subsided, 


l82  HOUR-GLASS   STOMACH  AND   GASTRIC  DIVERTICULA 

and  a  second,  further  to  the  right,  made  its  appearance.  The  passage 
of  fluid  from  one  compartment  to  the  other  may  sometimes  be  detected 
as  a  gurghng  sound.  The  stethoscope  is  useful  for  this  purpose,  but 
care  should  be  taken  not  to  mistake  the  normal  deglutition  sounds  or  the 
pyloric  sound  for  the  gurgle  due  to  the  passage  of  liquid  through  an 
abnormal  constriction.  Moynihan,  after  outlining  the  empty  stomach, 
gives  a  Seidlitz  powder  in  two  portions;  the  upper  pouch  will  become 
distended  with  carbon  dioxide  some  seconds  before  the  lower.  In 
thin  persons  the  cautious  distention  of  the  stomach  with  air  by  means 
of  a  hand-bulb  may  render  the  bi-loculated  stomach  appreciable  to 
percussion  and  palpation,  or  even  to  inspection.  '  We  have  already 
(p.  55)  expressed  our  preference  for  this  method  over  distention  by  means 
of  a  Seidhtz  powder.  When,  after  a  measured  quantity  of  liquid  has 
been  poured  into  the  stomach,  a  large  portion  of  it  cannot  be  recovered, 
it  may  be  assumed  that  the  lost  portion  has  passed  into  the  pyloric 
pouch  (Wolfler's  first  sign).  When,  during  lavage,  the  water  has  all 
returned  clear,  and  there  then  comes  a  gush  of  cloudy  fluid  mixed  with 
gastric  contents,  it  has  been  assumed  by  Wolfler  (the  test  is  known  as  his 
second  sign)  that  the  clear  fluid  comes  from  the  cardiac  and  the  cloudy 
from  the  pyloric  pouch.  Under  similar  circumstances,  if  it  be  impos- 
sible to  recover  liquid  from  the  stomach  even  when  splashing  may 
be  detected  in  it,  it  may  be  assumed  that  the  fluid  and  air  are  contained 
in  the  pyloric  pouch,  where  the  stomach  tube  cannot  reach.  This, 
which  is  spoken  of  as  "paradoxical  dilatation,"  is  known  as  Jaworski's 
sign. 

If  all  these  signs  were  present  in  any  one  case  it  might  be  safe  to 
conclude  that  hour-glass  constriction  of  the  stomach  existed;  but  as 
each  one  may  exceptionally  be  observed  in  other  conditions,  notably 
in  marked  gastric  dilatation,  the  assertion  before  operation  in  these 
cases  that  hour-glass  stomach  exists  is  in  many  instances  a  happy 
guess. 

A  more  satisfactory  outline  of  the  stomach  may  be  obtained  by 
means  of  fluroscopy,  after  the  ingestion  of  an  opaque  meal  (see  p.  61). 
Only  when  the  loculation  of  the  stomach  remains  constantly  unaltered 
during  a  prolonged  period  of  observation,  is  it  safe  to  conclude  that  a 
true  hour-glass  stomach  is  present,  since  in  most  cases  a  pseudo-locula- 
tion  of  the  stomach  is  present  due  to  normal  peristaltic  contractions, 
or  to  temporary  spasm  caused  by  an  ulceration  along  the  lesser  curva- 
ture. Downes  and  LeWald,  as  noted  at  p.  225,  consider  a  dumb-bell 
shaped  hour-glass  stomach  rather  characteristic  of  syphilitic  disease 
of  the  organ. 


TREATMENT  153 

Treatment. — When  surgical  treatment  is  undertaken  for  this  con- 
dition a  choice  of  operation  has  to  be  made  among  the  following:  (i) 
Digital  divulsion  of  the  constricted  orifice  by  means  of  gastrotomy; 
(2)  Gastroplasty  or  Gastro-anastomosis;  (3)  Gastro-gastrostomy; 
(4)  Gastro-jejunostomy;  and  (5)  Partial  Gastrectomy. 

The  statistics  of  these  various  procedures  have  been  investigated 
by  Schomerus.  Digital  divulsion  alone  seems  to  have  been  employed 
in  only  one  reported  case,  by  Moynihan  (1904),  who  adopted  this 
method  under  the  impression  that  he  was  dealing  with  an  inoperable 
malignant  growth.  The  patient  made  a  satisfactory  recovery,  was 
relieved  of  her  gastric  symptoms,  the  tumor  disappeared,  and  she  was 
still  in  good  health  more  than  two  years  later.  Blake  (1903)  employed 
divulsion  in  a  patient  whose  stomach  presented  a  tight  stricture  close  to 
the  cardiac  orifice,  but  as  he  also  did  a  gastro-jejunostomy,  in  the  py- 
loric pouch,  some  of  the  benefit  derived  from  the  intervention  may  have 
been  due  to  the  latter  procedure.  In  spite  of  the  successful  termination 
in  these  cases,  divulsion  is  not  now  an  accepted  form  of  treatment,  ex- 
cept in  rare  instances  where  the  constriction  is  so  near  the  cardia  as  to 
be  inaccessible  from  without  the  stomach.  As  in  the  case  of  pyloric 
obstruction,  divulsion  may  be  regarded  as  dangerous,  uncertain,  and 
in  every  way  less  satisfactory  than  the  other  forms  of  treatment  to  be 
described. 

Gastroplasty,^  analogous  to  pyloroplasty,  is  said  to  have  been  per- 
formed first  by  Bardeleben  in  1889;  this  operation  was  attended  by  a 
fatal  result;  but  Krukenberg  in  1892  employed  it  successfully,  as  did 
Doyen  and  other  surgeons  soon  afterwards.  Gastroplasty  is  limited 
in  its  application  to  stomachs  where  the  constriction  is  benign,  unat- 
tended by  induration  or  active  ulceration,  and  where  the  pylorus  is  not 
itelf  strictured.  The  employment  of  pyloroplasty  as  well  as  gastro- 
plasty would  only  be  complicating  one  not  very  satisfactory  operation 
by  another  still  less  promising.  Schloffer  in  one  case  complicated  by 
pyloric  stenosis  successfully  combined  gastroplasty  with  anterior  ante- 
colic  gastro-jejunostomy  in  the  pyloric  pouch.  A  modification  of 
gastroplasty,  analogous  to  Finney's  pyloroplasty,  was  introduced  by 
Kammerer  (1903),  and  has  been  successfully  employed  by  him  and 

'  Under  the  name  of  gastroplasty  Nicoladoni  suggested  the  substitution  of  the  transverse 
colon  for  the  stomach  after  a  circular  resection  of  the  latter.  Although  commended  by 
Kocher,  it  does  not  appear  to  have  been  employed,  and  is  mentioned  here  only  to  avoid 
confusion  of  terms.  The  same  term,  gastroplasty,  is  used  by  Jedlicka  to  describe  an  opera- 
tion consisting  in  resection  of  gastric  ulcers,  with  restoration  of  the  gastric  wall  by  the  sliding 
flap  method  commonly  adopted  in  plastic  surgery. 


184  HOUR-GLASS    STOMACH    AND    GASTRIC   DRERTICULA 

by  Other  surgeons.  It  may  be  conveniently  designated  Gastro-anasto- 
mosis.  Biidinger  (1901)  employed,  unsuccessfully,  a  flap  method  of 
gastroplasty. 

Each  method  may  no  doubt  be  suitable  in  certain  cases,  but  as  a 
general  rule  gastroplast}^  is  less  successful  than  one  of  the  methods 
presently  to  be  described.  Schomerus  (1904)  collected  47  cases  of 
gastroplasty  for  hour-glass  stomach,  with  5  deaths  (10.6  per  cent,  mor- 
tality); and  5  cases  in  which  pyloroplasty  was  also  done  (20  per  cent, 
mortality) ;  as  well  as  4  cases  in  which  gastro-jejunostomy  was  performed, 
with  a  mortality  of  25  per  cent.  Although  the  operative  mortality 
(10.6  per  cent.)  of  simple  gastroplasty  is  thus  seen  to  be  moderate 
(some  of  the  deaths  cannot  be  attributed  to  the  operation),  the  remote 
results  have  been  disappointing.  Paterson  found  (1906)  that  "in  at 
least  25  per  cent,  of  the  patients  who  have  recovered,  either  no  relief 
has  followed. or  relapse  has  occurred  subsequently." 

Gastro-gastrostom\\  which,  under  the  name  of  gastro-anastomosis, 
was  first  employed,  and  successfully,  by  Wolfler  in  1894,  is  even  more 
limited  in  its  application  than  is  gastroplasty.  Unless  the  two  pouches 
of  the  stomach  can  be  approximated  without  tension,  the  operation  is 
not  only  difficult  of  execution,  but  may  be  attended  by  a  fatal  result 
from  giving  way  of  the  sutures.  It  is  therefore  contra-indicated  when 
the  cardiac  pouch  is  small,  when  the  scar  is  wide-spreading,  or  when  many 
adhesions  are  present.  In  inoperable  cases  of  malignant  disease  it  is 
possible  that  some  temporary  relief  of  sjTnptoms  might  be  thus  ob- 
tained, but  usually  in  these,  as  in  benign  afl'ections,  better  results  will 
follow  gastro-jejunostomy.  The  main  indication,  we  think,  forgastro- 
gastrostomy  is  in  the  treatment  of  an  hour-glass  constriction  with  large 
pyloric  pouch  in  the  presence  of  pj^loric  obstruction,  when  the  pj^loric 
pouch  may  be  successfully  drained  by  gastro-jejunostomy.  If  pyloric 
stenosis  does  not  exist,  gastro-jejunostomy  in  the  cardiac  pouch  is  to 
be  preferred;  though  if  the  symptoms  are  due  to  dilatation  of  the  cardiac 
pouch  without  marked  stenosis  of  the  lumen  between  this  and  the 
pyloric  pouch,  gastro-gastrostomy  may  prove  efTectual,  as  in  Wolfler's 
patient.  We  have  found  references  to  44  operations  by  gastro-gastros- 
tomy, with  5  deaths,  a  mortahty  of  11.4  per  cent.  The  end  results  in 
most  cases  are  not  known,  but  definite  recurrence  was  noted  in  2 
patients,  5  and  7  years  respectively  after  operation,  A  patient  aged 
79  years  operated  on  by  the  junior  author  at  the  Walter  Reed  General 
Hospital  for  carcinomatous  hour-glass  stomach,  regained  his  health  and 
resurjied  his  normal  life  for  about  6  months,  but  then  died  rapidly  from 
extension  of  the  disease. 


TREATMENT 


185 


Gastro-jejunostomy. — Veyrasset  (1908)  collected  73  cases  in  which 
gastro-jejunostomy  had  been  done  for  hour-glass  stomach.  Among 
these  patients,  14  died  (19.1  per  cent,  mortality).  Recurrences  are 
extremely  rare.  Paterson  (1906)  found  only  2  recurrences  among  more 
than  30  patients  whom  he  traced;  and  in  one  of  these  the  return  of 
symptoms  was  "clearly  due  to  the  coexistence  of  pyloric  stenosis." 
The  anatomosis  should  of  course  be  made  with  the  cardiac  pouch;  and 
as  the  existence  of  this  pouch,  and  consequently  the  presence  of  hour- 
glass stomach,  has  been  overlooked  at  operation  by  some  very  compe- 
tent surgeons,  it  is  well  to  bear  in  mind  Moynihan's  advice,  always  to 
make  a  point  of  examining  the  whole  stomach  from  esophagus  to  duo- 
denum, before  undertaking  any  operation  on  it  whatever.  If  pyloric 
stenosis  coexists  with  hour-glass  constriction,  simple  gastro-jejunos- 
tomy will  not  effect  a  cure,  unless  the  pyloric  pouch  be  very  small 
indeed. 

Hacker  was  the  first  (1895)  to  consider  the  treatment  of  double 
gastric  stenosis,  and  the  principles  which 
he  then  laid  down  guide  the  surgeon  still. 
His  proposals  were:  (i)  To  combine  gas- 
troplasty, resection,  or  gastro-gastrostomy 
with  pyloroplasty,  pylorectomy,  or  gastro- 
jejunostomy in  the  pyloric  pouch;  or  (2) 
that  gastro-gastrostomy  should  be  com- 
bined in  one  opening  with  gastro-jejunos- 
tomy, so  thai ,  in  other  words,  both  gastric 
pouches  should  drain  through  the  one 
gastro-intestinal  anastomosis.  Mikulicz  is 
said  to  have  adopted  this  method  in  con- 
nection with  a  gastroplasty.  Finally,  v. 
Hacker  proposed  a  double  gastro-jejun- 
ostomy, uniting  each  gastric  pouch 
separately  with  a  loop  of  the  jejunum. 
This  method  was  also  advocated  (1896) 
by  Wier  and  Foote,  by  whose  names 
it   is   generally    known    in   this    country. 

According  to  Monprofit  (1904),  Clement,  of  Fribourg,  did  an  anterior 
gastro-jejunostomy  "in-Y"  with  double  lateral  anastomosis  to 
the  gastric  pouches  (Fig.  48).  Monprofit  proposed  a  double 
gastro-jejunostomy  "in-Y,"  after  Roux's  method  by  implantation; 
which  appears  to  us  a  more  complicated  operation  and  one  no 
more   likely  to  be   successful  than  that  employed  by  Clement.     In 


Fig.  48. — Diagram  of  Double 
Anterior  Gastro-jejunostomy  in-Y 
according  to  the  M  ethod  of  Clement 
of  Fribourg  for  a  case  of  Trifid 
Stomach. 


i86 


HOUR-GLASS    STOMACH   AND    GASTRIC   DIVERTICULA 


the  patient  with  trifid  stomach  operated  on  by  Moynihan,  gastro- 
gastrostomy  was  employed  to  unite  the  cardiac  and  median  pouches, 
the  constriction  between  the  latter  and  the  pyloric  pouch  was  di- 
lated by  the  fingers,  and  the  pyloric  pouch  was  drained  by  gastro- 
jejunostomy. In  Paterson's  similar  case,  gastroplasty  was  employed 
to  connect  the  pouches,  and  gastro-jejunostomy  was  done  in  the 
pyloric  pouch,  which  was  the  largest  of  the  three.  His  patient  was  in 
good  health  two  years  later. 

Of  these  various  operative  combinations,  it  appears  to  us  that 
these  are  to  be  preferred :  (i)  With  small  cardiac  pouch,  gastro-gastros- 
tomy  or  gastroplasty  with  gastro-jejunostomy  in  the  pyloric  pouch;  (2) 
with  large  cardiac  pouch,  Finney's  pyloroplasty  with  gastro-jejunos- 
tomy in  the  cardiac  pouch;  (3)  with  very  small  pyloric  pouch  either 
(a)  gastro-jejunostomy  in  the  cardiac  pouch  alone,  (b)  gastro-jejunos- 
tomy in  the  cardiac  pouch  combined  with  gastro-gastrostomy  or 
gastroplasty,  or  (c)  lateral  gastro-duodenostomy,  that  is,  an  anasto- 
mosis between  the  cardiac  pouch  and  the  duodenum,  as  successfully 
practised  in  one  such  case  by  Schnitzler. 


Fig.    49. — Cylindrical    Gastrectomy 
or  Sleeve  Resection. 


Fig.  50.  —  Circular  Gastror- 
rhaphy  (End  to  End  Suture)  after 
Cylindrical  Gastrectomy. 


In  six  cases  of  hour-glass  stomach  under  the  care  of  the  senior  author 
no  deaths  have  occured :  gastro-jejunostomy  alone  was  employed  in  one 
patient;  gastro-jejunostomy  combined  with  gastro-gastrostomy  in  two 
patients;  while  the  sixth  patient,  as  already  mentioned,  remained  well 
more  than  four  years  after  the  performance  of  gastro-gastrostomy  and 
Finney's  pyloroplasty.  If  there  were  malignant  disease,  our  preference 
would  naturally  be  for  excision,  where  practicable.  C.  H.  Mayo  (1920) 
reports  from  the  Mayo  Chnic  89  operations  for  hour-glass  stomach, 
with  7.4  per  cent,  mortality.  He  prefers  cylindrical  resection  of  the 
stomach  (Figs.  49  and  50),  combined  with  gastro-jejunostomy;  and  for 
recurrence  advocates  partial  gastrectomy. 


TREATMENT 


187 


Gastrectomy  for  hour-glass  stomach,  even  when  the  obstruction  is 
benign,  has  been  more  frequently  employed  of  late  years  than  was 
formerly  the  case  when  it  appeared  to  be  unnecessarily  severe.  Scho- 
merus  (1904)  collected  8  such  operations,  with  one  death.  In  six 
cases  (Bergmann,  Hahn,  Korte,  Krause,  Kiimmell,  Zeller)  circular 
gastrorrhaphy  was  done  after  resection,  the  lumen  of  the  stomach  thus 
being  restored  without  resort  to  gastro-jejunostomy.  In  Hedlund's 
patient  the  cardiac  pouch  was  closed  by  sutures,  and  then  the  py- 
lorus was  united  with  the  posterior  wall  of  the  cardiac  portion  of  the 
stomach  by  Kocher's  method  of  implantation.  Biidinger,  after 
closing  each  portion  of  the  stomach  separately,  did  a  posterior  retro- 
colic  gastro-jejunostomy.  The  only  fatal  result  was  in  Zeller's 
patient  (1893),  and  it  was  due  to  the  perforation  of  another  ulcer. 

Operations  for  Hour-glass  Stomach 
(After  Schomerus,  1904) 


Operation 


Cases 


Died 


Mortality 
per  cent. 


Resection 

Digital  divulsion 

Gastroplasty 

Gastroplasty  and  pyloroplasty 

Gastroplasty  and  gastro-jejunostomy 

Gastro-gastrostomy 

Gastro-gastrostomy  and  gastro-jejunost  omy 
Gastro-jejunostomy 


47 
5 
4 

19 
2 

52 


138 


17 


I2-S 
00.0 
10.6 
20.0 
25.0 
16.0 
00.0 

ii-S 


12.3 


Operations  for  Hour-glass  Stomach 
(Statistics  published  since  1908) 


Operation 


Cases 


Died 


Mortality, 
per  cent. 


Partial  gastrectomy 

Cylindrical  resection  (mediogastric) 

Resection  (not  specified) 

Gastroplasty 

Gastroplasty  and  gastro-jejunostomy 

Gastroplasty  and  Finney's  pyloroplasty 

Gastro-gastrostomy 

Gastro-gastrostomy  and  gastro-jejunostomy 

Gastro-jejunostomy 

Gastro-jejunostomy  (double) 


83 
8 

12 
2 
5 
3 

31 
4 

75 
5 

228 


7.2 
12.5 
16.66 
50.00 
00.0 
00.0 

9-7 
00.0 

9-3 
00.0 

8.7 


l88  HOUR-GLASS    STOMACH   AND    GASTRIC   DIVERTICULA 

Among  83  cases  of  gastrectomy  for  hour-glass  stomach,  which 
we  have  collected  since  the  publication  of  the  first  edition  of  this  work, 
there  have  been  only  6  deaths,  a  mortality  of  7.2  per  cent.  In 
selected  cases,  therefore,  excision  appears  to  be  the  method  of  choice. 

Gastric  Diverticiila. — Distinct  diverticula  of  the  stomach  are  very 
rare.  They  are  divided  by  systematic  writers  into  those  due  to  pres- 
sure, and  those  due  to  traction.  Every  case  of  dilated  stomach  from 
stenosis  is  really  an  example  of  a  pressure  diverticulum,  the  deformity 
in  cases  of  hour-glass  stomach  sometimes  assuming  a  form  more  char- 
acteristically pouched.  Of  the  distinct  diverticula,  the  form  due  to 
traction  is  less  unusual,  and  is  produced  by  adhesions  between  the 
stomach  and  neighboring  structures,  especially  the  pancreas,  the  liver, 
and  the  diaphragm  in  the  region  of  the  cardia.  Zahn  (1899)  observed 
a  gastric  diverticulum  in  which  both  pressure  and  traction  were  prob- 
ably causative  factors.  Horrocks  (1907)  recorded  a  case  which  he 
regarded  as  congenital. 

Almost  invariably  the  primary  cause  is  gastric  ulcer,  though  a  few 
examples  are  recorded  from  carcinoma.  If  the  pouch  is  so  situated  and 
of  such  conformation  as  to  favor  the  lodgment  of  food,  it  may  when  thus 
distended  simulate  a  malignant  tumor.  Diagnosis  before  operation 
or  autopsy  is  almost  impossible  without  the  aid  of  the  X-rays.  Treat- 
ment must  be  adapted  to  suit  the  condition  as  found.  Lieblein  and 
Hilgenreiner  (1905)  say  that  in  case  the  diverticulum  is  small,  and  not 
prone  to  collect  gastric  contents,  a  gastro-enterostomy  will  suflSice  to 
effect  a  cure,  by  relieving  pressure  and  allowing  the  distended  pouch 
to  contract.  Of  course  gastrolysis  must  in  most  cases  be  an  integral 
part  of  the  operation  and  it  might  then  become  possible  simply  to 
invert  the  pouch  into  the  stomach  and  close  its  base  by  sutures,  as 
in  the  analogous  conditions  in  the  esophagus.  In  other  cases  excision 
of  the  pouch  will  be  required.  This  may  prove  a  difficult  and 
dangerous  operation.  Gastro-gastrostomy  might  in  some  cases  be 
preferable. 

Few  patients  appear  to  have  been  subjected  to  operation.  Kola- 
czek  (1896),  in  a  patient  in  whom  there  was  present  a  mass  in  the 
epigastric  region,  adherent  to  the  abdominal  wall,  made  a  diagnosis 
of  ulcerating  leiomyoma  of  the  stomach.  This  diagnosis  was  based 
on  the  long  duration  of  the  tumor,  which  excluded  malignancy;  and 
on  the  fact  that  he  considered  leiomyoma  the  least  rare  form  of  benign 
tumor.  He  excised  the  mass,  which  proved  to  be  a  diverticulum  of  the 
stomach   involving   the   pancreas.     The   patient    recovered   and    was 


TREATMENT    OF    GASTRIC    DIVERTICULA  1 89 

reported  well  six  months  later.  Another  operation,  by  Mosetig- 
Moorhof,  was  reported  by  Silbermark  (1904).  The  diagnosis  in  this 
case  was  osteomyelitis  or  malignant  growth  of  the  left  costal  margin. 
Extirpation  was  undertaken,  and  the  gastric  pouch  was  unwittingly 
opened,  without,  however,  invading  the  general  peritoneal  cavity, 
which  was  shut  off  by  adhesions.  The  tract  was  found  to  be  lined 
with  mucous  membrane,  and  a  sound  passed  into  the  stomach  through 
the  nose  came  out  through  the  abdominal  wound.  A  tube  was  passed 
into  the  duodenal  end  of  the  stomach  from  the  wound,  and  the  gastric 
opening  was  tamponaded.  One  week  later  the  abdomen  was  opened 
in  the  median  line,  the  stomach  was  dissected  free  from  the  anterior 
abdominal  wall,  the  edges  of  the  ulcerated  area,  in  which  the  diver- 
ticulum had  formed,  were  freshened,  and  the  stomach  was  closed  by 
sutures,  reinforced  by  an  omental  graft.  The  patient  recovered,  and 
was  reported  in  good  health  one  month  later.  Other  operations,  in 
some  of  which  the  diverticulum  was  not  recognized  until  after  excision 
of  the  diseased  portion  of  the  stomach,  have  been  recorded  by  Barjon 
and  Delore  (1912),  Chutro  (igio),  C.  H.  Mayo  (1912),  Little  (1910), 
Jones  (1909)  and  Borzesky  (19 14). 


CHAPTER  VIII 
BENIGN  DISEASES  OF  THE  DUODENUM 

Duodenal  Ulcer 

Duodenal  ulcer,  according  to  MojTiihan,  was  first  recognized  as  a 
clinical  entity  by  Travers,  who  in  1817  reported  three  cases  of  perfora- 
tion. Surgical  treatment  for  duodenal  ulcer  was  at  first  confined 
solely  to  the  attempted  repair  of  perforations.  It  was  Sidney  Jones,  in 
1888,  who  first  operated  on  a  patient  with  a  duodenal  perforation.  No 
diagnosis  other  than  peritonitis  was  made,  and  the  perforation  was 
discovered  only  at  postmortem  examination.  Four  similar  operations, 
with  fatal  results,  followed  this  first  resort  to  surgery,  and  it  remained 

for  Gould  (1893)  to  find  and  to  suture  the 
ulcer,  although  his  patient  survived  only  six 
hours.  Five  other  fatal  operations  followed 
Gould's;  but  finally  a  patient  operated  on 
1  by  H.  P.  Dean,  in  1894,  recovered  from  the 

^  1^^  operation,  but  died  two  months  later  from  in- 

testinal obstruction.    The  patient  of  Landerer 
"^  and  Glucksmann  (1896)  survived  six  months, 

Pig.  si.— Duodenal  Ulcer ^^^    then   died   of    another  perforation   of 

Acute.  Showing  Appearance  of     the  duodcnum;    but  Dunn's  patient,  oper- 

Stippling  when  Serous  coat  is  .  . 

Abraded  by  Gauze.    Prom  a     ated  On "  m  this  Same  vear,  is  Credited  with 

Patient  in  the  Lankenau  Hos-  ^ 

pital  permanent  recovery. 

Until  the  publication  in  1893  by  Perry 
and  Shaw  of  their  studies  of  duodenal  ulcer,  the  condition  possessed 
little  or  no  surgical  interest.  Codivilla  operated  in  the  same  year 
for  symptoms  of  pyloric  obstruction;  he  found  the  latter  present  and 
that  it  was  caused  by  a  duodenal  ulcer.  It  was  Robert  F.  Weir,  how- 
ever, who  first  (in  1900)  roused  surgical  attention  to  the  frequency  of 
duodenal  ulcer  and  especially  to  cases  of  perforation.  No  one  has 
done  more  than  Moj-nihan  himself  to  arouse  interest  in  chronic 
duodenal  ulcer  as  a  disease  susceptible  of  cure  by  surgical  means. 

All  ulcers  on  the  duodenal  side  of  the  pyloric  vein,  as  described  by 
Mayo  and  by  Moynihan,  are  classed  as  duodenal.     Mayo  says:  "A 

190 


DUODENAL   ULCER 


191 


short  stumpy  vein  comes  out  from  above,  and  another  from  below,  the 
pylorus. "  These  veins,  he  points  out,  are  quite  unlike  vessels  in  other 
situations  of  the  stomach,  and  when  once  recognized  serve  readily  to 
locate  the  pyloric  ring.  Hartmann,  however,  who  is  a  keen  observer, 
denies  the  constancy  of  the  pyloric  vein;  for  our  own  part,  though  we 
have  found  it  recognizable  in  the  vast  majority  of  instances,  unless 
obscured  by  adhesions,  we  do  not  regard  it  as  an  infallible  indication  of 
the  location  of  the  pylorus.  Gastric  ulcers,  except  the  acute  perforat- 
ing variety,  are  not  very  usual  close  to  the  pyloric  ring;  and  when  a 
callous  ulcer  does  occur  here  it  is  not  apt  to  be  mistaken  for  a  duodenal 


Pig.  52.- 


-Microphotograph  of  a  fully  Developed    Duodenal  Ulcer, 
the  Lankenau  Hospital.     (Dr.  Reiman.) 


Prom  a  Patient  'in 


ulcer  so  much  as  for  a  gastric  (pyloric)  carcinoma,  owing  to  the  muscular 
hj^ertrophy  and  edema  which  accompany  it  and  give  it  its  resemblance 
to  a  tumor.  Until  these  pyloric  veins  were  adopted  as  a  limiting  land- 
mark, most  duodenal  ulcers  were  classed  as  pyloric,  i.e.,  gastric,  and 
duodenal  ulcer  was  considered  a  much  rarer  affection  than  gastric  ulcer. 
At  present,  quite  the  reverse  is  true,  and  in  the  statistics  of  all  large 
clinics  duodenal  ulcers  predominate.  During  a  period  of  seven  years 
at  theLankenau  Hospital  there  were  subjected  to  operation  215  patients 
with  duodenal  ulcer,  and  only  53  with  gastric  ulcer,  or  less  than  one- 
fifth  of  the  whole  series  of  patients  with  gastric  and  duodenal  ulcer 
(Fig.  27,  p.'yi). 


192 


BENIGN    DISEASES    OF    THE    DUODENUM 


About  95  per  cent,  of  duodenal  ulcers  b'e  within  4  cm.  of  the  pylorus 
and  most  often  upon  the  anterior  or  upper  surface  of  the  bowel.  A 
certain  number  of  these  ulcers  actually  involve  the  pyloric  ring  and 
may  even  e.xtend  into  the  stomach.  An  important  variety  which  often 
is  overlooked,  and  to  which  Codman  (1909)  and  more  recently  Geof- 
frey Jefferson  (191 6)  have  called  attention,  is  an  ulcer  lying  in  the 
duodeno-pyloric  fornix  (Fig.  53). 

In  regard  to  the  causes  of  duodenal  ulcer,  no  more  is  known  than  of 
those  of  ulcer  of  the  stomach.  Its  usual  location  lends  support  to  the 
theory  that  trauma  by  the  acid  chyme  as  it  is  squirted  through  the  py- 
lorus may  act  as  a  predisposing  cause.     Mayo  (191 5)  contends  that  the 

ingestion  of  very  hot  liquids  is  a  predis- 
posing cause,  since  all  liquids  are  ejected 
rapidly  from  the  stomach  through  the  mech- 
anism of  the  canalis  gastrkus,  to  which 
reference  was  made  at  p.  46.  The  influence 
of  extensive  burns  of  the  body  in  causing 
acute  ulcerations  of  the  duodenum,  while 
recognized  since  the  days  of  Curling  ( 1 842) , 
has  never  been  thoroughly  explained. 
Alexander  (191 2)  observed  this  complica- 
tion in  four  out  of  twenty- seven  patients 
with  extensive  burns. 

Duodenal  ulcer  seems  to  have  a  pre- 
dilection for  male  adults,  especially  for 
those  between  thirty  and  fifty  years  of 
age,  whereas  gastric  ulcer  is  most  charac- 
teristic of  young  women  under  thirty  years 
of  age.  Notable  exceptions  to  this  rule, 
however,  are  occasionally  encountered. 
Genrich,  according  to  Gandy  (1899),  has  recorded  a  perforation  of  a 
duodenal  ulcer  in  an  infant  21  hours  old;  and  Torday  (1906)  reported  a 
duodenal  ulcer  found  at  autopsy  in  an  infant  of  nine  months.  Hahn, 
according  to  Lieblein  and  Hilgenreiner  (1905),  found  at  autopsy  on  an 
infant  two  days  old  a  duodenal  ulcer  which  had  caused  death  from 
hemorrhage.  Cases  such  as  these,  in  infants,  are  no  doubt  of  toxemic 
origin.  Among  Collin's  273  patients.  16  (6.22  per  cent.)  were  less  than 
one  year  old. 

Symptoms. — While    in    general    characteristics   the    symptoms   of 
ulcer  of  the  duodenum  bear  a  resemblance  to  those  of  gastric  ulcer,  there 


Fig.   53. — Duodeno-pyloric    Ulc. 
(After  Geoffrey  Jefferson.) 


SYMPTOMS  OF  DUODENAL  ULCER  1 93 

are  certain  factors  sufficiently  distinctive,  if  they  be  present,  to  render 
possible  a  positive  diagnosis  of  the  site  of  the  lesion. 

Duodenal  ulcer  is  even  more  apt  to  be  latent  than  is  ulcer  of  the 
stomach.  Perforation  is  not  unusually  the  first  symptom  calling 
for  medical  advice.  Among  151  cases  analyzed  by  Perry  and  Shaw 
the  first  symptom  in  no  less  than  91  was  the  hemorrhage  or  perforation 
from  which  the  patient  died.  F.  Brunner  found  a  history  of  previous 
symptoms  of  duodenal  ulcer  could  be  obtained  in  only  56  per  cent,  of 
the  patients  with  perforation  whose  cases  he  analyzed.  Weir,  however, 
found  the  previous  history  positive  on  this  point  in  25  (73  per  cent.) 
of  34  cases  of  duodenal  perforation.  This  corresponds  closely  with  the 
statistics  of  the  Lankenau  Hospital,  where  a  previous  history  of 
gastric  disease  was  obtained  in  75  per  cent,  of  cases. 

Pain  in  duodenal  ulcer  typically  does  not  occur  until  two  or  three 
hours  after  the  ingestion  of  food.  Indeed  many  patients  will  entirely 
deny  the  existence  of  pain,  and  only  on  close  questioning  will  admit 
that  they  feel  more  comfortable  when  the  stomach  has  some  food  in 
it,  than  they  do  soon  before  taking  their  meals.  They  frequently 
acknowledge  that  they  are  averse  to  letting  their  stomachs  remain 
empty  more  than  two  or  three  hours  at  a  time.  They  will  not  sleep 
soundly  the  night  through  unless  they  have  eaten  a  little  late  supper 
just  before  retiring;  or  they  will  be  in  the  habit  of  taking  a  cracker 
and  a  glass  of  milk  during  the  night  when  they  wake  up  in  the  small 
hours.  All  these  are  manifestations  of  what  Moynihan  has  graphically 
called  the  "hunger  pain"  of  duodenal  ulcer.  But  it  is  to  be  noted 
that  patients  are  rarely  aware  that  it  is  the  discomfort  which  impels 
them  to  keep  their  stomach  constantly  occupied.  They  rather  think 
that  the  eating  at  shorter  intervals  than  other  people  is  an  idiosyncrasy 
not  based  on  any  pathological  cause.  It  is  supposed  that  the  reason  the 
presence  of  food  in  the  stomach  keeps  in  abeyance  the  pain,  is  because 
thus  the  acid  gastric  secretion  is  neutralized  before  passing  the  pylorus, 
and  thus  irritation  of  the  ulcer  is  prevented.  Pain  is  less  often  referred 
than  in  ulcer  of  the  stomach. 

Vomiting  is  unusual  in  duodenal  ulcer,  unless  stenosis  of  the  pylorus 
is  present.  Hematemesis  is  equally  rare.  Melena,  is  not  as  usual  in 
ulcer  of  the  duodenum  as  is  hematemesis  in  gastric  ulcer.  The  quan- 
tity of  blood  in  the  bowel  movements,  however,  is  frequently  very 
small,  and  often  escapes  the  attention  of  the  patient  altogether. 
The  tests  for  occult  blood  are  considered  by  some  of  great  aid  in  reaching 
a  diagnosis. 


194  BENIGN   DISEASES    OF    THE    DUODENUM 

Tenderness  in  duodenal  ulcer  is  almost  invariably  close  to  the 
right  costal  border,  and  characteristically  is  not  confined  to  one  spot, 
but  extends  through  the  descending  portion  of  the  duodenum. 

Jaundice  is  a  rare  sign,  and  is  generally  thought  to  indicate  that  the 
papilla  of  Vater  is  invaded  by  the  ulcer,  though  it  may  be  due  merely  to 
concurrent  catarrhal  duodenitis,  or  to  independent  disease  of  the 
biliary  tract.  We  have  seen  several  cases  of  duodenal  ulcer  with 
jaundice  from  stone  in  the  common  duct. 

Perforation  is  usually  said  to  be  more  frequent  than  in  gastric  ulcer. 
The  older  statistics,  as  given  by  Laspeyres  (1902),  tended  to  support 
this  contention:  Chvostek  found  it  to  occur  in  42  per  cent,  of  pa- 
tients, Collin  in  69  per  cent.,  and  Oppenheimer  in  48  per  cent,  of  pa- 
tients. But  Robson  noted  perforation  only  in  10  per  cent,  of  his 
operative  cases;  and  among  272  operations  for  duodenal  ulcer  Mayo 
recorded  only  66  (24  per  cent.)  for  perforation  (16  acute,  13  subacute, 
and  3  7  chronic  perforations) .  The  statistics  from  the  Lankenau  Hospital 
are  in  accord  with  !Mayo's  and  with  Robson's:  in  a  series  of  179  cases  of 
duodenal  ulcer,  26  perforations  were  encountered  (23  acute,  3  chronic), 
or  14.5  per  cent.;  while  in  a  series  of  44  cases  of  gastric  ulcer  there  were 
9  perforations  (7  acute,  2  subacute)  or  20.4  per  cent.  In  the  59  cases 
of  gastric  and  duodenal  perforation  reported  by  Scully  (1918),  the  48 
gastric  perforations  formed  9  per  cent,  of  the  cases  of  gastric  ulcer  seen, 
and  the  11  duodenal  perforations  formed  15  per  cent,  of  cases  of  duo- 
denal ulcer  seen.  It  seems  probable  that  the  much  smaller  proportion 
of  perforations  in  duodenal  ulcer  in  these  statistics  than  in  those  quoted 
from  Chvostek,  Collin,  and  Oppenheim,  may  be  due  to  the  much  more 
frequent  recognition  of  the  s\'mptoms  of  uncomplicated  duodenal  ulcer 
at  the  present  time. 

F.  Brunner  found  perforation  of  duodenal  ulcer  occurred  ten 
times  in  the  male  to  once  in  the  female;  whereas  perforation  of 
gastric  ulcer  occurred  onlj^  once  in  the  male  to  four  times  in  the 
female. 

The  perforation  is  much  more  frequent  in  the  first  portion  of  the 
duodenum,  and  usually  is  on  its  anterior  wall.  Obviously  the  reason 
for  this  is  the  rarity  with  which  an  ulcer  is  found  in  other  parts  of  the 
duodenum.  The  rarity  of  perforation  of  the  lower  wall,  as  well  as  on 
other  retroperitoneal  portions  of  the  duodenum,  is  no  doubt  due  to  the 
protection  afforded  by  the  pancreas  and  other  retro-peritoneal  struc- 
tures. Perforations  into  neighboring  organs  seldom  have  been  ob- 
served. Perforation  of  the  duodenum  into  the  stomach  appears  to 
be  unknown;  that  of  the  stomach  into  the  duodenum,  though  extremely 


DIAGNOSIS    OF   DUODENAL   ULCER  1 95 

rare,  has  nevertheless  been  recorded  in  a  few  instances.  Subphrenic 
abscess  was  caused  by  duodenal  perforation  in  6  out  of  58  cases  of  the 
former  condition  collected  by  Nowak.  Petren  (191 5)  has  published 
notes  of  six  cases,  including  two  personal  observations,  which  he 
considers  undoubted  examples  of  retroperitoneal  perforation  of  duo- 
denal ulcers.  All  but  one  of  these  patients  died,  though  Perry  and 
Shaw's  patient  lived  for  more  than  5  months  after  the  retroperitoneal 
abscesses  had  been  incised. 

In  regard  to  the  symptomatology  of  perforation  of  duodenal  ulcer, 
little  need  be  added  to  what  has  already  been  said  (at  p.  85)  in  con- 
nection with  gastric  perforations.  The  great  frequency  with  which 
neglected  duodenal  perforation  simulates  appendicitis  should  be  borne 
in  mind.  Moynihan  in  1901  collected  49  operations  for  perforation 
of  the  duodenum,  in  18  of  which  the  diagnosis  had  been  appendicitis. 
If  at  an  operation  for  appendicitis,  especially  in  a  male  adult,  no  lesion 
of  the  appendix  be  found  sufilicient  to  account  for  the  state  of  the  peri- 
toneal cavity,  the  surgeon  will  do  well  immediately  to  examine  the 
region  of  the  pylorus.  In  very  many  cases  his  search  for  a  perforation 
will  be  rewarded. 

Differential  Diagnosis. — There  are  three  affections  which  are 
frequently  confused  with  chronic  duodenal  ulcer:  gastric  ulcer,  chronic 
appendicitis,  and  gall-bladder  disease.  From  gastric  ulcer  it  usually 
may  be  distinguished  by  observing  the  long  interval  after  food  before 
the  occurrence  of  pain  in  cases  of  duodenal  ulcer;  and  by  the  occurrence 
of  exacerbations  in  cold  or  wet  weather,  which  are  unusual  if  not  entirely 
absent  in  patients  with  ulcer  of  the  stomach.  Meunier  (191 2)  says 
that  in  gastric  ulcer  immediate  relief  of  pain  is  secured  by  the  ingestion 
of  milk,  while  in  duodenal  ulcer  this  relief  is  delayed  for  5,  10,  or  15 
minutes,  and  then  occurs  suddenly,  and  with  belching  of  gas.  Bolton 
(1913)  points  out  that  in  duodenal  ulcer,  a  heavy  meal,  especially  of 
meat,  staves  off  pain  a  long  time;  and  when  pain  begins  it  lasts  until 
the  patient  eats  again,  and  eating  at  once  relieves  it.  Gastric  symp- 
toms, he  thinks  (such  as  fulness,  flatulence,  eructations,  etc.)  favor 
the  existence  of  gastric  rather  than  of  duodenal  ulcer,  as  also  does  the 
only  partial  or  occasional  relief  from  pain  by  eating.  Moynihan, 
on  the  other  hand,  as  noted  below,  thinks  flatulent  dyspepsia  is 
characteristic  not  of  gastric  ulcer  but  of  gall-stone  disease.  From 
gall-bladder  disease  duodenal  ulcer  is  to  be  distinguished:  (i)  by  the 
regularity  of  the  symptoms,  occurring  always  at  a  specified  time  after 
food,  and  recurring  as  regularly,  and  being  as  regularly  relieved  by 
the  ingestion  of  food;  (2)  by  the  complete  absence  of  symptoms  during 


196 


BENIGN    DISEASES    OF    THE    DUODENUM 


the  intervals  between  exacerbations;  and  (3)  by  the  fact  that  pain  in 
duodenal  ulcer  is  very  seldom  unendurable,  while  in  attacks  of  biliary 
colic  it  frequently  requires  morphin  for  its  relief.  An  acid  dyspepsia, 
says  Moynihan,  indicates  duodenal  ulcer;  while  flatulent  dyspepsia 
implies  the  presence  of  gall-stones.  The  differentiation  from  chronic 
appendicitis  is  very  difficult;  it  seems  at  present  that  the  mistake  is 
more  often  made  of  thinking  the  patient  has  a  duodenal  ulcer,  when  the 
real  trouble  is  chronic  appendicitis,  than  vice  versa.  The  symptoms  of 
chronic  appendicitis,  however,  do  not  bear  such  an  invariable  relation 


Fig.   54. — Microphotograph   from   Specimen   of    Duodenal    Ulcer  Excised  from   Case 
Represented  in  Pig.  55.     This  Section  Shows  the  Ulcer  still  Ulcerating,  though  its  Gross , 
Appearance  Indicated  it  was  Healed.     (Dr.  Reiman.) 

in  time  of  appearance  to  the  intake  of  food  as  do  those  due  to  ulcer  of 
the  duodenum,  though  they  usually  are  brought  on  by  indiscretions  of 
diet;  but  they  may  develop  without  any  apparent  indiscretions  in 
diet,  especially  following  unusual  exercise.  Moreover,  an  exacerba- 
tion of  appendicitis  almost  invariably  keeps  the  patient  to  his  bed  for 
a  few  days,  while  in  the  exacerbations  of  duodenal  ulcer  this  is  unusual. 
Ingestion  of  food  usually  eases  the  pain  of  duodenal  ulcer,  while  it 
will  have  no  effect  on  that  due  to  chronic  appendicitis,  or  will  make  it 
worse.  Moreover  in  chronic  appendicitis  there  are  no  free  intervals 
when  dyspepsia  is  entirely  absent  for  months  at  a  time. 

Prognosis. — Duodenal  ulcer  is  a  less  serious  disease  than  gastric 
ulcer  only  because  of  the  great  infrequency  with  which  malignant 
changes  occur  in  duodenal  ulcer.     Unless  some  treatment  is  appHed 


TREATMENT    OF    DUODENAL    ULCER 


197 


which  will  not  only  relieve  the  symptoms  but  entirely  cure  the  disease, 
the  patient  is  in  constant  danger  of  the  acute  complications  (hemorrhage 
and  perforation)  which  together  occur  in  from  15  to  20  per  cent,  of 
cases.  It  is  possible  that  modern  medical  treatment  may  do  some- 
thing more  than  secure  latency  of  symptoms,  but  we  know  of  no  facts 
which  render  this  certain.  Should,  however,  a  duodenal  ulcer  really 
heal  under  medical  treatment,  it  is  not  probable  that  further  trouble 
will  be  caused  by  obstruction  from  the  cicatri.x.  Yet  an  ulcer  which 
appears  entirely  healed  on  gross  inspection  may  be  shown  by  the  micro- 
scope still  to  be  unhealed  (Figs.  54  and  55);  while  in  rare  instances 
hour-glass  duodenum  has  developed  (p.  203);  and  in  most  patients 
more  or  less  crippling  periduodenal  adhesions  will  remain,  interfering 
with  evacuation  of  the  stomach,  distorting  the  gall-bladder,  and  render- 
ing the  patient's  life  miserable.  On  the  other  hand,  surgical  treatment 
offers  for  duodenal  ulcer  no  less  sure  a  cure  than  for  ulcer  of  the 
stomach,  and  the  operative  mortality  is  as  low.  It  has  been  possible 
to  trace  60  patients  with  duodenal  ulcer,  operated  on  by  the  senior  author 
during  the  years  1909  to  1914  inclusive.  Of  these  60  patients,  51  or 
85  per  cent,  were  ascertained  to  be  free  from  symptoms  one  year  or 
more  after  operation.  Seven  of  the  remaining  9  patients  complained 
of  nothing  more  serious  than  "occasional  epigastric  distress;"  one  had 
"persistent  nausea"  and  one  was  reported  "unimproved."  Later 
statistics  of  cases  of  duodenal  ulcer  are  included  with  those  of  gastric 
ulcer  tabulated  at  p.  105.  They  indicate  that  approximately  90  per 
cent,  of  the  patients  traced  have  been  found  free  from  symptoms. 

The  prognosis  when  perforation  has  actually  occurred  is  much  less 
favorable.  The  actual  figures  collected  by  Robson,  comprising  155 
operations  from  various  sources,  gave  a  total  mortality  of  66  per  cent., 
as  may  be  seen  in  the  following  table: 

Operations  for  Duodenal  Perfoeation  (1Q07) 


Time 


Cases 


Under  24  hours. 
Over  24  hours. 
Not  stated.  . 

Total 


61 
31 


Deaths 


5- 
28 


Mortality 
per  cent. 

37-;o 
82.5 
go.  30 

66.66 


Fortunately  at  the  present  time  perforations  of  the  stomach  and 
duodenum  are  recognized  much  earlier  than  was  the  case  even  a  few 
years  ago,  and  this  factor,  as  well  as  more  rational   post-operative 


198  BENIGN   DISEASES    OF    THE    DUODENUM 

treatment,  has  resulted  in  a  considerable  reduction  in  the  mortality. 
The  statistics  of  operations  for  perforations  of  the  stomach  or  duodenum 
are  tabulated  at  p.  122. 

Treatment. — When  a  diagnosis  of  duodenal  ulcer  has  been  defi- 
nitely made  we  believe  it  is  a  pure  waste  of  time  to  postpone  opera- 
tive treatment.  Delay  is  justifiable  only 
when  there  is  reasonable  doubt  as  to  the 
diagnosis.  And  when  such  a  doubt  cannot 
be  dismissed  within  reasonable  time  under 
medical  treatment,  we  believe  it  is  the 
part  of  wisdom  and  of  a  sound  mind  to 
subject  the  patient  to  an  exploratory 
operation. 

The  best  treatment,  whenever  appli- 
cable, is  excision  of  the  ulcer.  If  the  ulcer 
is  easily  accessible,  as  is  almost  always  the 

Fig.     55.  —  Duodenal     Ulcer  -jr'     -^       ^     i  ^i.  ^      • 

Cicatrizing,  see  Pig.  54.    From     case  if   Situated   on  the  anterior  or  upper 

a-Patient  in  the  Lankenau  Hos-  T^rg^H  ^f  j^g  bowel,  its  complete  removal  by 
Pital.  .   .  5 

excision  presents  no  difficulty  whatever. 
When  it  is  not  easily  accessible,  its  complete  removal  may  be  an 
operation  of  some  difficulty,  not  to  say  danger,  to  one  not  thoroughly 
accustomed  to  abdominal  surgery.  If  the  surgeon  does  not  feel  himself 
competent,  he  should  content  himself  with  the  performance  of  gastro- 
jejunostomy. In  all  cases  this  latter  procedure  is  to  be  regarded  as  an 
integral  part  of  the  operation  for  the  cure  of  duodenal  ulcer.  Coffey,  Sherren 
and  others  indeed  still  consider  gastro-jejunostomy  alone  as  suflScient. 
Thus,  Sherren  {1920),  with  an  experience  in  389  opeiations  for  chronic- 
duodenal  ulcer  (with  only  9  deaths),  adduces  the  following  facts  in  sup- 
port of  his  contention  that  gastro-jejunostomy  alone  is  sufficient:  in  8 
cases  he  examined  the  ulcer  post  mortem  at  periods  varying  from  6  days  to 
9  years  after  gastro-jejunostomy,  and  in  all  (except  that  with  only 
9  days  interval)  the  ulcei  was  healed;  in  21  cases  he  examined  the  ulcer 
at  a  later  operation,  at  intervals  varying  from  2  months  to  10  years 
after  the  gastro-jejunostomy,  and  in  all  cases  the  ulcer  had  healed. 
He  traced  348  patients  for  more  than  two  years  after  operation  for 
duodenal  ulcer,  and  found  3 18  or  91  percent,  were  cured.  So  he  concludes 
that,  unless  the  ulcer  is  adherent  to  another  viscus,  gastro-jejunostomy 
alone  will  cure  it.  But  we  believe  that  in  the  case  of  duodenal  ulcers 
as  in  those  affecting  the  stomach,  the  surgeon's  first  effort  should  be 
toward  removal  of  the  diseased  area;  and   that  gastro-jejunostomy, 


Plate  II 


(a)  Duodenal  Ulcer — Specimen  Secured  by  Excision.  Note  Deep,  Punched-out 
Crater,  Without  Evidences  of  Repair  in  Surrounding  Duodenal  Wall.  Male,  25  years, 
Symptoms  were  those  of  Chronic  Appendicitis,  but  Appendix  when  Exposed  Found  not 
Diseased  Enough  to  Account  for  the  Symptoms.  Stomach  then  Exposed  and  this  Juxta- 
pyloric  Ulcer  Found  in  Duodenum.      Path.  No.  9630.     I.ankfnau  Hospital. 


(b)  Duodenal  Ulcer  on  Posterior  Surface  of  Fir.it  Part  of  Duodenum — Specimen 
Secured  by  Excision.  Note  Typical  Punched-out  Crater,  with  Threatening  Perforation 
near  its  Centre.  Male.  37  Years,  Free  from  Symptoms  for  i  Year  after  Operation, 
then  Developed  Symptoms  of  Chronic  Cholecystitis,  for  which  Cholecystectomy  was  Done 
2*4  Years  after  Operation  on  Pylorus.     Path.  No.  9562.     Lankenau  Hospital. 

Face  p.  19S 


CONGENITAL   IMPERPORATION   OF    THE   DUODENUM  1 99 

through  indispensable  as  a  supplemental  operation,  though  effectual 
in  preventing  a  recurrence,  cannot  always  be  relied  upon  to  cure  an 
already  fully  developed  ulcer.  The  technique  of  excision  of  the  duo- 
denum is  discussed  at  p.  367.  Excision  of  isolated  ulcers  requires  no 
special  description. 

Xot  only  is  it  necessary  to  treat  the  duodenal  ulcer  at  the  time  of 
operation,  but  it  is  necessary  also  to  try  to  discover  the  focus  of  intra- 
abdominal infection  which  is  to  be  regarded  as  the  Jons  et  origo  mali. 
To  this  end  the  surgeon  should  also  inspect  the  bihary  tract,  and  if 
necessary  drain  the  gall-bladder.  The  frequency  of  an  accompanying 
pancreatitis  should  be  recollected.  An  even  more  constant  source 
of  infection  than  the  gall-bladder  is  the  vermiform  appendix,  and 
unless  there  is  some  distinct  centra-indication  this  obnoxious  structure 
should  be  removed.  This  usually  may  be  done  through  the  same 
incision  as  that  employed  for  exposure  of  the  upper  abdominal  organs; 
but  if  it  proves  difficult  to  deliver  the  appendix  through  the  upper 
abdominal  incision  it  is  better,  we  behove,  to  make  a  separate  incision 
over  the  appendix  rather  than  to  lengthen  unduly  the  upper  incision. 

When  perforation  has  occurred,  operation  at  the  earhest  possible 
moment  is  demanded.  The  sooner  the  surgeon  opens  the  peri- 
toneum, allows  the  extravasated  matters  to  escape,  and  closes  the 
perforation,  the  better  it  will  be  for  his  patient.  If  the  duodenum 
is  bound  dowTi  by  adhesions  and  the  site  of  perforation  is  not  easily 
accessible,  a  large  sand  pillow  under  the  lower  dorsal  spine,  as  in 
operations  on  the  biliary  tract,  will  prove  of  considerable  assistance 
in  bringing  the  duodenum  nearer  the  abdominal  incision.  The  per- 
foration should  be  closed  with  catgut  or  linen  sutures.  Usually  a 
purse-string  suture  is  sufficient  for  small  perforations;  while  larger 
openings  require  a  running  -suture  placed  either  in  the  long  axis  of 
the  bowel,  or  transversely,  whichever  proves  easiest  of  application. 
If  the  sutures  do  not  hold  well,  a  tag  of  omentum  should  be  stitched 
over  the  sutured  area.  Unless  the  peritonitis  is  extensive  and  the 
patient  in  a  precarious  condition,  we  advocate  also  in  cases  of  per- 
foration that  the  operation  be  completed  by  the  performance  of  gastro- 
jejunostomy. This  has  been  our  practice  for  a  number  of  j-ears, 
and  we  believe  our  results  justify  our  contention  that  gastro-jejunostomy 
promotes  recovery  (p.  127).  In  a  few  cases  in  which  the  duodenum  was 
extremely  friable  and  the  perforation  could  be  closed  only  imperfectly, 
resulting  in  temporary  leakage  of  duodenal  secretions  and  bile,  we 
feel  confident  that  the  recovery  of  the  patients  was  largely  attrib- 
utable to   the  existence  of  the  gastro-jejunal  anastomosis.     This  is 


200  BENIGN   DISEASES    OF    THE    DUODENUM 

especially  true  in  cases  of  subacute  perforations  of  the  stomach  and 
duodenum  unexpectedly  discovered  at  operations  undertaken  for 
supposedly  simple  (uncomplicated)  lesions.  In  such  cases  it  may 
be  impossible  to  make  sutures  hold  in  the  region  of  the  perforation, 
repeated  attempts  to  do  so  only  succeeding  in  enlarging  the  opening 
in  the  bowel;  while  resection  is  entirely  out  of  the  question.  Here 
the  patient's  salvation  depends  on  the  performance  of  gastro-jejunost- 
omy. 

Retroperitoneal  perforations  of  the  duodenum  usually  make  their 
presence  known  by  the  development  of  suppuration  in  the  loin  or 
flank,  or  occasionally  in  the  right  ihac  fossa.  The  abscess  should  be 
opened  where  most  accessible,  and  unless  the  discharge  of  duodenal 
contents  is  very  free,  a  reasonable  expectation  may  be  entertained 
that  the  fistula  will  close  spontaneously  as  is  the  case  with  most  fecal 
fistulae  following  the  drainage  of  appendicular  abscesses.  Should 
the  duodenal  fistula  show  no  tendency  to  close,  however,  in  the  course 
of  four  or  five  days,  the  surgeon  should  not  delay  too  long  to  open 
the  abdomen,  establish  a  gastro-jejunal  anastomosis  and  occlude  the 
pylorus  by  phcation  of  its  anterior  wall,  or  if  necessary  by  section 
and  closure  of  both  ends.  It  is  much  better  not  to  open  the  retro- 
peritoneal tissues  nor  to  make  any.  attempt  to  close  the  perforation 
by  suture. 

Miscellaneous  Affections  of  the  Duodenum 

Congenital  Imperforation  of  the  Duodenum,  examples  of  which 
rare  condition  have  been  recorded  by  Cleemann  (1874),  Trump  (1896), 
Stewart  (1898),  Weber  (1910)  and  others,  could  be  differentiated 
during  Ufe  from  imperforation  of  the  pylorus  only  if  the  occlusion 
were  below  the  papilla  of  Vater,  thus  allowing  bile  to  be  regurgitated 
into  the  stomach.  Should  a  diagnosis  be  made,  gastro-jejunostomy 
should  be  performed;  but  as  malformations  of  the  bile-tracts  and 
liver  sometimes  co-exist,  the  prognosis  is  exceptionally  gloomy.  In 
the  cases  just  referred  to,  the  occlusion  was  below  the  papilla  of  \'ater; 
in  cases  reported  by  Collum  (1895),  Emerson  (1890),  Hobson  (1893), 
and  others,  it  was  situated  above  the  entrance  of  the  bile-ducts.  A 
specimen  of  complete  congenital  occlusion  of  the  duodenum,  described 
by  Keith  (1910),  is  said  to  have  come  from  the  body  of  a  child  who 
lived  until  the  age  of  9  months. 

A  case  of  congenital  stricture  of  the  duodemim  in  a  girl  aged  13  days 
has  been  recorded  by  Shaw  and  Baldauf  (1907);  the  lumen  was  found 
at  autopsy  to  be  permeable  only  to  fluids  under  pressure.     The)'  cjuote 


STENOSIS   AND   CHRONIC   DILATATION    OF    THE   DUODENUM  20I 

Kuliga  as  having  collected  185  cases  of  congenital  occlusion  of  the 
intestines:  of  these,  46  (25  per  cent.)  were  of  the  duodenum,  94  of  the 
jejunum,  and  45  of  the  colon  and  rectum. 

According  to  Terry  and  Kilgore  (1916),  there  are  on  record  about  70 
cases  of  congenital  stenosis  of  the  duodenum.  They  report  a  case  of 
duodenal  stenosis  in  a  man  aged  24  years,  which  they  regarded  as 
congenital.     The  patient  died  from  peritonitis  after  gastro-jejunostomy. 

Acquired  Stenosis  of  the  Duodenum,  of  which  Anders  (191 2)  has 
collected  262  instances,  is  the  result,  in  more  than  half  the  cases,  of 
ulcer  of  the  duodenum.  Anders  gives  the  following  tabulation  of 
causes: 

Cause 


Ulcer  of  duodenum 

Compression  by  root  of  mesentery 

Carcinoma  of  duodenum 

Carcinoma  of  pancreas 

Sphincteric  action  of  muscular  layer  of  duodenum. 

.Adhesions 

Gallstones 

Growths 

Kinking 

Cysts  of  pancreas 

Miscellaneous 


Total . 


;ases 

Percentage 

140 

53-44 

29 

11.07 

23 

8.78 

16 

6. II 

15 

5-73 

12 

458 

9 

3-44 

4 

1-53 

3 

1. 14 

2 

0.  76 

9 

3-43 

262 

TOO. 00 

Aciite  occlusions  of  the  duodenum,  apparently  due  to  compression 
by  the  root  of  the  mesentery,  cannot  well  be  separated  from  cases  of 
acute  dilatation  of  the  stomach  fp.  145). 

The  operation  which  has  been  adopted  in  cases  of  duodenal  stric- 
ture by  Bazy  (1905),  Mackenzie  (1906),  and  others,  is  named  duodeno- 
plasty,  and  consists  in  longitudinal  incision  and  transverse  suture  of  the 
constricted  portion  of  the  bowel,  in  a  manner  similar  to  the  pyloro- 
plasty of  Heineke- Mikulicz.  If  the  adhesions  are  few  or  easily  sepa- 
rated, and  the  duodenal  wall  not  too  thick  or  friable,  this  is  a  better 
procedure  than  gastro-jejunostomy  in  cases  of  stenosis  due  to  changes  in 
the  intestinal  wall.  Of  course  if  the  stenosis  is  due  to  pressure  from 
outside  the  lumen  of  the  duodenum  and  if  the  pressure  can  be  removed 
(gall-stones,  pancreatic  cyst),  nothing  further  may  be  required.  If 
the  site  of  obstruction  is  inaccessible,  as  in  the  transverse  duodenum, 
a  duodeno-jejunostomy,  as  employed  successfully  by  Frank  (1913) 
in  a  child  aged  11  months,  is  a  more  rational  procedure  than  a  gastro- 
jejunostomy, as  in  the  latter  case  the  bile  and  pancreatic  secretions 
will  have  to  traverse  the  stomach  (retrograde  through  the  pylorus) 


202  BENIGN   DISEASES    OF    THE   DUODENUM 

before  reaching  the  jejunum.  Melchior  (1914)  adopted  gastro-jejunos- 
tomy  successfully  in  the  case  of  a  young  man  aged  19  years,  who  pre- 
sented symptoms  of  duodenal  obstruction  below  the  bile  papilla, 
found  at  operation  to  be  due  to  a  congenital  abnormality;  and  he 
justifies  the  adoption  of  gastro-jejunostomy  instead  of  duodeno- 
jejunostomy not  only  on  account  of  the  greater  simplicity  of  the 
operation,  but  also  because  experience  has  shown  that  the  duodenal 
secretions  readily  find  their  way  through  the  anastomosis  by  way  of  the 
pylorus  and  are  well  tolerated  by  the  stomach. 

Chronic  Dilatation  of  the  Duodenum  is  occasionally  seen.     It  is 
usually  due  to  an  obstruction  at  the  duodeno-jejunal  flexure  or  to 


Fig.   56. — Hour-glass  Duodenum  from  Cicatrizing  Ulcer.  Complicated  by  an  Ulcer  on  the 
Lesser  Curvature  ol  the  Stomach.      (From  a  Patient  in  tlir  Lankenan  Hospital.) 

pressure  from  the  root  of  the  mesentery.  Bloodgood's  observations 
(191 2)  tend  to  show  that  duodenal  dilatation  often  is  an  accompaniment 
of  redundant  cecum  and  enteroptosis,  the  resulting  tension  on  the 
mesentery  occluding  the  duodenum  where  the  latter  is  crossed  by  the 
superior  mesenteric  artery.  He  reports  4  out  of  5  patients  relieved  of 
their  symptoms;  by  resection  of  the  cecum  and  ascending  colon.  The 
symptoms  of  which  these  patients  complained  resembled  those  of  pylo- 
ric stenosis,  but  there  was  biHous  vomiting.  Gregoire  (1920)  has  also 
studied  the  subject,  reporting  5  cases:  he  thinks  recurrent  attacks  of 
bilious  vomiting,  with  very  marked  exhaustion  anil  sudden  loss  of 
weight,  and  without  such  pain  as  occurs  in  cholecystitis,  is  particularly 
characteristic.     The   diagnosis   may  often  be  made  with  reasonable 


HOUR-GLASS    DUODENUM  203 

certainty  if  the  fluoroscope  is  employed.  He  agrees  with  Bloodgood 
as  to  the  etiological  relation  of  congenital  anomahes  of  the  ascending 
colon  but  in  some  of  his  cases  demonstrated  that  it  was  the  taut 
middle  colic  artery  and  not  the  superior  mesenteric  which  was  respon- 
sible for  the  duodenal  obstruction.  He  employed  colopexy  in  his 
cases,  in  addition  to  gastro-jejunostomy.  The  same  objections  exist  to 
gastro-jejunostomy  alone  in  these  cases  as  in  those  of  stricture  of  the 
duodenum  mentioned  above.  Yet  Benjamin  (1914)  employed  gastro- 
jejunostomy in  a  man  aged  22  years,  and  reports  freedom  from  symp- 
toms nearly  a  year  after  operation.  Stavely  (1Q08)  successfully  adopted 
duodeno-jejunostomy,  as  have  Quain  (1920), 
Grouse  (1920),  and  Ashhurst  (192 1),  while 
Leriche  and  Sigaud  (1912)  report  restoration 
of  gastric  function,  by  a  gastro-jejunostom}-  | 
with  ligation  of  the  pylorus  to  exclude  the 
duodenum. 

Christian  has  recorded  (1907)  a  cast- 
where  chronic  dilatation  of  the  duodenum 
was  mistaken  for  hour-glass  stomach. 

There    can   be    httle  doubt   that   man_\- 
patients  with  symptoms  of  pyloric  obstruc- 
tion who  are  fotmd  at  operation    to  have       p,G.    57.  — Duodenal    Ulcer 
a  patent  pylorus    are  suffering    from  dila-    Cicatrized  and  Adherent  to  the 

^  ^  ■'  _     °  .        Pancreas,     Causing    Hour-glass 

tation   of    the    duodenum;    this  anomaly  will    Duodenum.      From    a   Patient 

be  recognized  by  the  surgeon  if  the  possibiUty  '"  ^  ^"  ^"^"  °^^' 
of  the  condition  is  kept  in  mind.  If  the  cecum  and  ascending  colon 
are  congenitally  mobile,  they  should  be  reattached  to  the  posterior 
parietal  peritoneum,  as  advised  by  Waugh  (p.  69),  and  if  this  seems 
insufficient  to  relieve  the  condition  gastro-jejunostomy  or  duodeno- 
jejunostomy should  be  done,  together  with  suspension  of  the  transverse 
colon  to  the  anterior  abdominal  wall  if  this  portion  of  the  large  bowel 
also  is  abnormally  ptosed.  Only  in  cases  where  the  walls  of  the  movable 
colon  have  become  grossly  thickened  by  long  continued  stasis  do  we 
believe  colectomy  will  be  indicated. 

Hour-glass  duodenum  usually  is  a  late  result  of  stricture,  following 
ulceration.  The  stricture  usually  is  above  the  bile  papilla,  frequently 
quite  close  to  the  pylorus  (Fig.  56).  Mackenzie  (1906)  published 
details  of  several  cases  of  this  malformation,  and  suggests  a  number 
of  operations  for  its  reUef.  He  has  himself  employed  gastro-jejunostomy 
in  two  patients:  cure  resulted  in  the  first  case,  which  appears  to  have 
been  a  stricture  rather  than  an  example  of  true  hour-glass  deformity; 


204  BENIGN   DISEASES    OF    THE   DUODENUM 

but  the  second  patient,  presenting  a  well  marked  deformity,  though 
much  improved  bj^  the  operation,  still  had  occasional  gastric  dis- 
comfort. Preferable  operations  are  duodenoplasty  (Ladeveze,  Bazy, 
Mackenzie);  duodeno-duodenostomy  (Mayo);  or  gastro-duodenostomy 
to  the  distal  pouch  of  the  duodenum.  All  these  procedures  are  much 
more  easily  executed  after  mobilization  of  the  duodenum. 

Eustermann  (1914)  reports  8  cases  of  hour-glass  duodenum  from 
the  Mayo  Clinic  (1907-1913):  posterior  gastro-jejunostomy  was  done 
in  7  cases,  and  excision  with  plastic  enlargement  in  the  eighth  patient. 
In  one  patient,  under  the  care  of  the  senior  author  at  the'Lankenau 
Hospital  fISIarch  27,  1913)  (Fig.  57)  posterior  gastro-jejunostomy  was 
adopted;  unfortunately  it  has  not  been  possible  to  trace  this  patient 
subsequent  to  his  discharge. 

Diverticula  of  the  duodenum  were  described  by  Chomel  (1710) 
and  by  Morgagni.  Lctullc  (1899)  noted  in  two  cases  little  pouches 
in  the  neighborhood  of  the  bile  papilla,  and  thought  they  were  to  be 
explained  as  a  congenital  anomaly  of  development  due  to  the  budding 
out  from  the  duodenum  of  processes,  as  in  the  formation  of  the  liver 
and  pancreas.  This  probably  is  the  true  explanation  of  most  cases 
which  are  not  clearly  due  to  traction  by  adhesions.  The  subject  was 
reviewed  at  length  by  Buschi  in  1911,  and  by  E.  C.  Moore  in  1920. 

Perry  and  Shaw  (1893)  classified  diverticula  of  the  duodenum  as  dis- 
tension and  traction  pouches.  Usually  found  close  to  the  papilla,  as 
in  Letulle's  patients,  they  are  next  most  frequent  at  the  pylorus. 
Usually  they  do  not  produce  symptoms,  and  are  found  at  autopsies  in 
the  aged.  The  development  of  pressure  pouches  is  aided  by  the  pre- 
sence of  the  pylorus  above  and  Ochsner's  sphincter  or  compression  by 
the  root  of  the  mesentery  below.  Traction  diverticula  are  less  usual, 
and  generally  are  due  to  perigastric  adhesions  the  result  of  ulcer  or 
cholecj'stitis ;  they  occur  mostly  in  the  first  part  of  the  duodenum. 
Perry  and  Shaw  mention  14  cases  of  pressure  diverticula,  and  found  at 
Guy's  Hospital  records  of  three  patients  with  traction  diverticula. 
The  diagnosis  often  may  be  made  by  the  Roentgen  rays  (Cole  and 
Roberts,  1920).  Excision  is  the  best  treatment.  Moore's  patient  was 
in  perfect  health  ^}i  years  after  excision  of  the  diverticulum. 


CHAPTER  IX 
BENIGN    TUMORS    OF   THE    STOMACH   AND    DUODENUM 

Benign  tumors  of  the  stomach  and  duodenum  are  rare.  As  has 
been  seen  in  the  preceding  pages,  a  palpable  mass,  when  not  mahgnant, 
is  almost  invariably  hyperplastic  or  inflammatory  in  origin.  The  non- 
malignant  neoplasms  most  frequently  encountered  in  the  stomach  are 
myoma,  adenoma  (including  polyp),  lipoma,  and  cysts. 

Before  proceeding  to  a  detailed  account  of  each  variety,  it  will  be 
well  to  state  in  a  few  words  the  general  characteristics  which  most  of 
these  growths  possess  in  common.  Although  found  most  frequently 
at  autopsy,  in  patients  who  as  a  rule  are  not  known  to  have  suffered 
from  gastric  s>Tnptoms  during  life,  it  is  evident  that  with  the  increasing 
number  of  operations  on  the  upper  abdomen,  more  of  these  tumors  are 
now  found  at  operation  than  formerly,  even  if  they  may  not  have  been 
correctly  diagnosticated  before  the  abdomen  was  opened. 

The  patient  is  usually  an  adult,  probably  more  often  female  than 
male,  who  has  suffered  from  gastric  indigestion  for  a  number  of  years. 
Pain  of  a  dragging  and  tearing  character  is  sometimes  a  prominent 
symptom.  Vomiting,  if  it  occurs  at  all,  usually  arises  a  half  hour  or 
an  hour  after  eating,  but  is  present  with  no  regularity  as  in  gastric 
ulcer.  The  vomiting  may  occur  only  once  or  twice  during  the  whole 
course  of  the  illness,  or  it  may,  especially  in  the  case  of  polypoid  growths, 
recur  whenever  gastric  peristalsis  is  e.xcited.  In  very  pronounced  poly- 
poid conditions  of  the  mucosa,  the  nausea  may  be  constant.  Hema- 
temesis  is  rare,  being  seen  most  often  in  adenomatous  tumors,  or  in 
myomatous  tumors  which  have  penetrated  the  cavity  of  the  stomach 
and  have  become  ulcerated.  The  blood  is  then  usually  clotted  before 
being  vomited;  the  vomiting  of  bright  red  blood  is  quite  unusual.  The 
tumors  in  the  course  of  time  are  prone  to  e-xcite  perigastsitis,  and  the 
adhesions  both  interfere  with  gastric  motility,  and  cause  increased  pain. 
Frequently  the  tumor,  though  of  fair  size,  is  not  palpable  because  held 
by  adhesions  beneath  the  costal  margin,  or  because  perigastritis  renders 
the  overlying  muscles  so  rigid  that  satisfactory  palpation  is  impossible. 
Large  subserous  tumors  of  the  stomach  with  a  long  pedicle  may,  on 
the  contrary,  be  very  movable,  and  occasionally  are  found  even  in  the 


2o6  BENIGN    TI'MORS    OF    THE    STOMACH    AND    DUODENUM 

hypogastric  region.  The  physical  signs  of  hour-glass  stomach  may  be 
simulated  by  submucous  growths  in  the  median  portion  of  the  stomach. 

The  long  duration  of  a  palpable  mass  is  the  chief  means  by  which 
malignant  disease  may  be  excluded.  A  diagnosis  of  benign  tumor  is 
sometimes  made  in  cases  of  inflammatory  hyperplasia ;  and  Kolaczek,  as 
already  mentioned  (p.  188),  diagnosed  leiomyoma  in  a  patient  with  a 
gastric  diverticulum  adherent  to  the  anterior  abdominal  wall. 

Myoma  and  Fibromyoma.^  Myoma  of  the  stomach  was  first  ob- 
served by  Morgagni.  Steiner  in  1898  collected  58  cases  of  myoma  of 
the  gastro-intestinal  canal.  21  of  which  were  situated  in  the  stomach, 
and  only  3  in  the  duodenum.  Hake  collected  59  additional  cases  in 
1912  (this  series  included  3  cases  of  myoma  of  the  appendix,  and  4 


Fig.    5S. — Fibroma   ot"   Posterior   Wall   of   Stomach.     One-half   Natural    Size.      From    a 
Specimen  in  the  Museum  of  the  Lankenau  Hospital. 

cases  of  myoma  of  the  rectum).  We  have  been  able  to  find  52  further 
cases,  recorded  since  the  publication  of  Hake's  paper.  This  makes  a 
total  of  125  cases  of  myoma  or  fil:)ro-m}'oma  of  the  stomach  so  that  it 
can  no  longer  be  regarded  as  an  excessively  rare  condition.  It  is  pro- 
bable, moreover,  that  very  small  myomata  are  sometimes  overlooked  at 
autopsy.  Among  3500  autopsies  at  Genf,  Tilger  (1893)  found  6  nut- 
sized  myomata  and  fibromyomata  of  the  stomach.  Bircher  (1908) 
recorded  a  case  of  pedunculated  fibroma  of  the  stomach. 

Generally  situated  along  one  or  the  other  curvature,  they  are  less 
unusual  close  to  the  jnlorus  than  at  the  cardia.  Arising  in  the  mus- 
cular tunic  of  the  stomach  wall,  they  grow  either  inward  or  outward, 
projecting  as  a  rounded  more  or  less  nodular  mass,  beneath  either  the 
mucous  membrane  or  the  peritoneal  surface  of  the  organ.     Being  at 


GASTRIC   MYOMA  20? 

first  attached  to  the  muscular  coat  by  a  pedicle,  this  may  become  ex- 
tremely attenuated,  as  in  Cernezzi's  case  (1902),  and  finally  all  connec- 
tion between  the  tumor  and  the  muscular  tunic  from  which  it  sprang 
may  be  lost  (Yirchow),  as  in  the  case  of  the  analogous  tumors  of  the 
uterus.  Gastric  myomata  are  almost  invariably  single  if  we  except 
certain  forms  of  polypus  which  are  really  more  adenomatous  or  fibro- 
matous  in  character. 

Internal  myomata,  as  those  are  called  which  project  into  the  cavity 
of  the  stomach,  frequently  become  ulcerated,  and  give  risetohemateme- 
sis  or  melena.  Fatal  hemorrhage  occurred  in  cases  recorded  by  Kemke, 
Miodowski  and  Niemeyer.  These  tumors  are  seldom  very  large,  and 
often  cannot  be  detected  through  the  abdominal  wall.  External 
myomata,  on  the  other  hand,  sometimes  grow  to  an  immense  size,  the 
tumor  in  Erlach's  patient  weighing  5400  grammes,  and  reaching  in  the 
case  of  Perls  and  Neelsen  fi886)  deep  into  the  pelvis,  and  weighing  6000 
grams.  The  gastric  origin  of  such  large  tumors  frequently  is  not  recog- 
nized, both  on  account  of  their  position  in  the  abdomen,  and  because  of 
secondary  attachments  which  are  formed  to  other  structures.  Yet  ad- 
hesions to  the  anterior  abdominal  wall  are  unusual  and  free  mobility 
is  a  frequent  characteristic;  especially  noteworthy  is  the  fact  that  the 
uterus  can  almost  always  be  excluded  as  the  seat  of  the  disease.  In  23 
of  the  reported  cases  the  tumor  is  recorded  as  being  internal,  in  21  as 
being  external,  and  in  i  the  growth  was  still  interstitial  in  character 
when  excised  (Poirier,  1902)  on  account  of  pylorospasm.  Of  25  patients 
19  were  over  40  years  of  age,  and  13  of  these  were  more  than  50  years 
old.     Of  27  patients  whose  sex  is  stated,  11  were  males  and  16  females. 

The  great  majority  of  gastric  myomata  are  strictl}'  benign,  but 
occasionally  they  are  malignant.  There  is  great  confusion  among 
pathologists  as  to  the  classification  of  these  malignant  varieties.  In  a 
great  many  myomata  there  have  been  noted  certain  areas  of  edema, 
amounting  in  some  instances  to  myxomatous  degeneration.  When 
this  condition  is  pronounced,  the  term  myxomyoma  is  applied  (Kemke). 
Cysts  may  be  formed  thus,  or  as  the  result  of  hemorrhage  into  the 
tumor.  Certain  cases  have  been  reported  (Goullioud  and  Mollard, 
Goullioud,  Brodowski,  Hansemann,  Cohn,  Shuyveninoff)  in  which 
gastric  myomata,  with  more  or  less  myxomatous  degeneration,  have 
given  rise  to  metastases  in  the  liver,  peritoneum,  and  other  structures; 
and  in  these  metastatic  nodules  the  primary  growth  was  in  large  part 
reproduced,  the  cells  being  clearly  smooth  muscle  cells,  with  an  admix- 
ture of  myxomatous,  or  degenerated  cells.  In  their  interpretation 
of  the  "degenerated"  cells,  either  in  the  primary  tumor  or  in  the  metas- 


2o8  BENIGN   TUMORS    OF    THE    STOMACH    AND    DUODENUM 

tases,  pathologists  are  not  in  accord.  They  were  long  regarded  as 
sarcoma  cells,  and  the  primary  tumor  was  said  to  have  undergone 
sarcomatous  degeneration.  But  some  writers,  following  the  teaching 
of  Bard  of  Lyons,  and  maintaining  the  theory  of  the  specificity  of  tumor 
cells,  claim  that  tumors  such  as  those  just  described  are  pure  myomata, 
and  that  the  so-called  sarcoma  cells  are  nothing  more  than  immature 
smooth  muscle  cells.  These  authorities  (Parrot  and  Berard;  Devic 
and  Gallavardin ;  Giuliani)  name  such  a  tumor  Leiomyoma  mahgnum. 
Steiner,  Cernezzi,  and  others,  distinguish  between  sarcomatous  myo- 
mata, and  myosarcomata;  the  latter  being  a  malignant  tumor  ab 
initio,  whereas  a  sarcomatous  myoma  is  one  which,  though  at  first 
benign,  finally  undergoes  malignant  degeneration.  Of  course  there  is 
theoretically  no  reason  why  the  connective  tissue  cells,  present  in  a 
fully  developed  myoma,  should  not,  as  described  by  Steiner  (1898), 
eventually  become  sarcomatous,  just  as  they  might  do  were  the  muscle 
cells  themselves  normal,  thus  forming  a  pure  sarcoma.  It  is  therefore 
theoretically  possible  for  a  myoma  subsequently  to  become  sarcoma- 
tous in  this  manner;  but  such  a  tumor,  if  it  exist,  would  be  more  cor- 
rectly named  a  sarcomatous  myoma,  or  a  myoma  sarcomatodes,  than  a 
myosarcoma.  And  from  our  knowledge  of  pathological  processes  in 
general  it  appears  hardly  safe  to  conclude  that  muscle  cells,  even  when 
already  perverted  into  tumor  formation,  can  subsequently,  by  meta- 
plasia, become  sarcoma  cells.  It  seems  to  us  more  rational  to  look  upon 
these  myomata  as  being  either  sarcomatous  tumors  in  muscular  tissue 
(myosarcoma  ab  origine),  or  as  being  examples  of  leiomyoma  malignum, 
as  described  by  Devic  and  Gallavardin  and  by  Giuliani.  It  may  be 
mentioned  in  passing  that  similar  tumors  giving  muscular  metastases 
have  been  described  in  connection  with  the  uterus. 

Further  confusion  is  added  to  the  subject  by  the  class  of  myomata 
in  which  angeiomatous  changes  exist.  Some  of  these  tumors  are 
undoubtedly  malignant,  and  are  classed  by  some  writers  as  angeio- 
sarcomata,  and  by  others  as  endotheliomata  (von  Bergmann;  Nichols). 
Cyst  formation  is  frequent  in  these  angeio-myomata. 

Magnus-Alsleben  (1903)  observed  post-morten  five  patients  with 
adenomyoma  of  the  stomach,  and  he  concludes  that  in  these  tumors  the 
adenoma  is  the  primary  change,  and  that  it  is  later  crowded  out,  so 
to  speak,  by  the  myomatous  overgrowth.  Some  authors  have  regarded 
certain  instances  of  hyperemesis  lactantium  as  due  to  a  congenital 
myoma  of  the  pylorus.     (See    p.  132). 

In  a  case  recorded  by  Monro  and  McLaren  (1901),  a  pedunculated 
myoma  near  the  pylorus  was  present  in  a  stomach  on  whose  lesser 


ADENOMA   AND    PAPILLOMA  209 

curvature  was  a  carcinoma.  The  two  growths  had  no  connection. 
Wade  (1913)  has  recorded  a  case  of  intussusception  of  the  stomach  and 
duodenum  into  the  jejunum,  due  to  the  presence  of  a  pedunculated 
myoma  near  the  pylorus.  After  reducing  the  intussusception  the  tumor 
was  discovered  and  excised,  the  patient  recovering. 

Operative  treatment  should  be  undertaken  as  soon  as  a  gastric 
myoma  makes  its  appearance  known.  It  is  usually  possible  to  remove 
the  growth  by  resection  of  that  part  of  the  gastric  wall  from  which  it 
sprang;  but  occasionally  formal  excision  (partial  gastrectomy)  is 
required. 

In  the  first  edition  of  this  work  we  gave  details  of  14  operations  for 
myoma  or  fibromyoma  of  the  stomach,  reported  by  various  authors. 
Among  these  cases  there  were  8  recoveries  and  5  deaths,  the  result  in  one 
case  not  being  recorded.  Since  that  date  (1909)  we  have  references 
to  31  additional  operations  of  the  same  nature,  24  patients  recovering, 
I  dying  and  the  result  in  6  cases  not  being  recorded.  The  whole  series 
includes  38  terminated  excisions  or  resections,  with  6  deaths. 

Adenoma  and  Papilloma. — Gastric  adenomata  are  met  with  in 
two  forms:  (A)  Sessile  pedunculated  growths,  usually  single,  and 
practically  indistinguishable  from  mucous  papillomata;  (B)  Poly- 
adenomata,  or  mucous  polypi.  Ebstein  (1864)  found  14  instances  of 
gastric  polyps  among  600  necropsies. 

(A)  The  former  variety,  which  is  usually  understood  when  the 
term  adenoma  is  employed,  projects  into  the  cavity  of  the  stomach, 
usually  in  the  pyloric  region,  in  the  form  of  a  rounded,  smooth  or 
slightly  lobulated  tumor,  evidently  composed  almost  solely  of  hyper- 
trophied  mucous  membrane.  When  solitary,  such  tumors  have  been 
known  to  grow  to  the  size  of  an  apple,  or  even  to  that  of  a  fetal  head 
at  term  (Chaput,  1895).  Sklifossowsky  (1898)  recorded  under  the 
name  of  papilloma  of  the  stomach  two  cases  presenting  much  the  same 
macroscopic  and  microscopic  appearances  as  adenomata.  Mauler 
collected  all  cases  of  adeno-papillomata  recorded  up  to  1898.  Hay  em 
(1895)  called  attention  to  two  cases  of  adenoma  the  structure  of  which 
resembled  Brumier's  glands,  and  which  appeared  to  originate  in  the 
mucosa;  the  same  condition  has  been  since  observed  by  other  patholo- 
gists. These  tumors  usually  rapidly  penetrate  the  muscularis  mucosae, 
and  proliferate  in  the  submucous  tissues.  The  more  usual  form  of 
adenoma  is  strictly  a  mucous  growth.  It  proliferates  above  the  muscu- 
laris mucosae,  projecting  into  the  cavity  of  the  stomach;  it  very 
rarely  becomes  ulcerated,  unless  malignant,  or  unless  it  prohferates 
around  the  border  of  a  gastric  ulcer.     It  is  usually  single,  but  several 

14 


!IO 


BENIGN    TUMORS    OF    THE    STOMACH    AND    DUODENV.M 


may  be  present  in  different  parts  of  the  stomach.     In  many  patients  the 
entire  intestinal  tract  is  involved. 

When  pedunculated,  and  with  enough  fibrous  tissue  in  its  pedi- 
cle to  warrant  the  name  of  fibro-adenoma,  this  tumor  forms  one  of  the 
commonest  varieties  of  gastric  polypus.  An  intragastric  polyp  may 
occlude  the  pylorus,  thus  simulating  pyloric  stenosis  from  other  and 
more  frequent  causes;  and  when  easily  displaced  may  produce  inter- 
mittent dilatation  of  the  stomach,  as  in  a  remarkable  case  reported 
in  igoo  by  Bennett  (Figs.  59,  60).  Gibson  (1907)  recorded  a  similar 
case.     In  one  case  quoted  by  Fenwick  (1903)  fatal  intussusception  of 


Fig.  59. — Polypus   of    Stomach   near 
Pylorus.      (Bennett.) 


Fig.  60. — Gastric  Polypus  near  Pylorus 
Acting  as  Ball-valve.      {Bennett.) 


the  duodenum  was  produced  b\-  a  polyp  just  l)elow  the  i)ylorus. 
Wade's  case  of  pedunculated  myoma  of  the  stomach,  causing  intus- 
susception, has  already  been  mentioned  (p.  209). 

In  general  it  may  be  said  that  a  fully  developed  gastric  polyp 
is  more  apt  to  ])roduce  symptoms  than  is  any  other  form  of  benign 
gastric  tumor.  Multiple  polypi  were  found  by  Stevens  (1896)  at 
autopsy  on  a  patient  who  had  been  subject  to  constant  epileptic  fits, 
with  an  aura  arising  in  the  stomach.  Such  cases  are  of  interest  in  con- 
nection with  the  subject  of  gastric  tetany.  McCosh  recorded  (1900) 
a  case  of  gangrenous  gastritis  from  strangulation  of  a  polyp  in  the 
stomach. 

It  is  difficult  to  draw  a  boundary  line  between  adenomatous  changes 
frequently  encountered  in  the  stomach,  in  association  with  unhealed 
ulcers,  and  certain  histological  appearances  which  by  some  pathologists 
are  considered  pre-cancerous  in  nature.  Ledderhose  (1913)  says 
Doening  found  gastric  polyps  associated  with  carcinoma  in  24  out  of 
50  cases,  and  \'erse  in  22  out  of  57  cases:  he  ((uotes  Thorbeck  as  stating 


MUCOUS    POLYPI  211 

that  50  per  cent,  show  a  tendency  to  carcinomatous  change,  and  W'ech- 
selmann  as  claiming  malignancy  in  from  50  to  60  per  cent,  of  cases. 
For  a  further  discussion  of  pre-cancerous  changes  the  reader  is  referred 
to  the  chapter  on  Gastric  Carcinoma  (p.  248).  The  relation  of  myoma 
to  adenoma,  studied  by  Magnus-Alsleben,  has  already  been  referred  to 
at  p.  208. 

(B)  Polyadenomata,  or  mucous  polypi  of  the  stomach,  are  usualh- 
regarded  as  in  some  way  the  result  of  chronic  gastritis.  They  are  as  a 
rule  widely  distributed  over  the  interior  of  the  stomach,  transforming 
its  surface  into  a  pulpy  mass,  from  which  mucus  can  readily  be  squeezed. 
Each  polyp  is  more  or  less  distinct  from  the  others,  and  none  are  larger 
than  peas  or  small  cherries.  The  centre  part,  or  stalk,  of  each  indi- 
vidual tumor  is  composed  of  fibrous  tissue,  containing  blood  vessels  and 
l\Tnphatics,  and  representing  the  normal  submucosa.  Over  this  core  a 
thickened  hypertrophied  layer  of  smooth  muscular  tissue  is  found, 
corresponding  to  the  muscularis  mucosa;;  while  the  free  surface  of  the 
tumor,  frequently  cystic,  is  composed  of  hypertrophied  and  tortuous 
mucous  glands.  These  dilated  glands  are  said,  to  resemble  closely 
the  uriniferous  tubules  in  the  cortex  of  the  kidney.  According  to 
Menetrier  (1899),  the  cysts  result  from  involvement  of  the  ducts  of  the 
glands;  whereas  when  the  fundi  of  the  glands  are  chiefly  affected,  the 
cysts  are  few  in  number  and  of  small  size.  These  mucous  polypi  are 
freely  movable  over  the  subjacent  tissues,  and  the  neighboring  lym- 
phatic nodes  are  never  affected.  Yet  Norman  recorded  (1893)  a  case 
of  polyadenomata,  apparently  belonging  to  this  class,  in  which  the 
change  was  not  considered  malignant  although  the  glandular  tissue  had 
broken  through  the  muscularis  mucosa'  ami  ])roliferated  in  the  submu- 
cous tissue.  Bier  (1908)  did  gastro-jejunostomy  for  a  similar  affection 
(dififuse  poljposis),  the  patient  being  reported  as  improved  18  months 
later,  although  microscopical  examination  of  a  portion  of  the  gastric 
mucosa  had  shown  "early  malignant  changes." 

Menetrier  also  describes  a  form  of  mucous  polypus  which  he  calls 
" polyadeiwmc  en  nappe  "  in  which  condition  the  adenomatous  forma- 
tion is  not  confined  to  any  circumscribed  area  or  areas,  with  the  forma- 
tion of  distinct  polypi;  but  the  hypertrophy  and  hyperplasia  affect 
simultaneously  all  the  glands  over  a  fairly  large  area,  or  even  through 
the  whole  stomach. 

All  these  adenomatous  tumors  (the  adenoma  proper  and  the  mucous 
polypi)  have  these  distinguishing  histological  features:  they  are  sepa- 
rated on  the  one  hand  from  simple  inflammatory  or  hypertrophic 
changes  by  the  fact  that  although  there  is  hyperplasia  of  the  glandular 


2T2  BEXIGX    TUMORS    OF    THE    STOMACH    AXD    DUODENUM 

Structures,  yet  the  pepsin  or  ox^mtic  cells  present  in  normal  glands  fail 
to  be  reproduced  in  the  adenomatous  neoplasms;  and,  on  the  other 
hand,  they  are  distinguishable  from  adeno-carcinoma  by  the  fact  that 
nowhere  may  the  epithelial  cells  of  the  adenoma  be  found  to  have 
penetrated  the  muscularis  mucosas  or  to  be  deprived  of  their  normal 
basement  membrane. 

Symptoms. — Unless  pedunculated,  adenoma  of  the  stomach  is 
characterized  by  no  very  well  defined  symptoms.  In  cases  recorded 
by  Gourrand  (1790),  and  by  Quain  and  Beardsley  (1856)  a  gastric 
polj-'pus  was  vomited.  In  the  case  of  mucous  pol\-pi  the  patient 
may  complain  of  constant  gastric  discomfort,  and  nausea  may  be  a 
prominent  feature  of  the  case.  This  condition  has  been  suspected 
during  life,  and  the  suspicion  confirmed  at  autopsy,  in  the  case  of 
patients  who  have  suffered  from  a  sensation  of  worms  crawling  around 
the  stomach. 

A  correct  diagnosis  can  rarely  be  made,  even  with  the  aid  of  skia- 
graphy; it  is  sometimes  possible,  however,  to  determine  the  presence  of 
a  benign  tumor.  In  other  case  an  exploratory  operation  is  undertaken 
for  the  s3-mptoms  of  pyloric  stenosis,  or  even  of  prolonged  gastric 
indigestion.  Usually  it  has  been  possible  to  excise  the  tumor  with  or 
without  partial  resection  of  the  gastric  wall.  Many  more  such  opera- 
tions are  recorded  for  adenomata  which  showed  malignant  changes  than 
for  those  which  were  undoubtedly  benign. 

Operations  for  the  removal  of  adenomata  or  papillomata  have  been 
recorded  by: 

1.  Lange  (1892).     Recovery. 

2.  Chaput  (1895).     Recovery. 

3.  Lyman  11896).     Death  in  one  month. 

4.  Bennett  (1900).     Recovery. 

5.  Robson  and  Moynihen  (1904).     Recovery. 

6.  Hinds  (ibid).     Recovery. 

7.  Wegele  (1909).     Recovery. 

8.  Wynhausen  (1909).     Recoverv. 

9.  Sherren  (191 1).     Recovery. 

10.  Khosroyeff  (191 2).     Recovery. 

11.  Ponomarew  (1912).     Death. 

12.  Bruchi  (1913).     Recovery. 

13.  M\-er  (19 13).     Death. 

14.  Ledderhose  (19 13).     Recovery. 

15.  Heinz  (^1914).     Recovery. 


LIPOMA  213 

16.  Stoner  (1914).     Recovery. 

17.  Campbell  (1915).     Recovery. 

18.  Basch  (Berg.)  (1916).     Recovery. 

19.  Basch  (Roth)  (1916).     Recovery. 

Lipoma. — These  tumors  may  arise  either  in  the  sumbucous  or  the 
subserous  adipose  tissue.  Small  lipomata,  the  size  of  peas  or  beans,  are 
not  unusual.  In  such  cases  the  masses  of  fat  are  probably  not  heterolo- 
gous, but  merely  a  localized  increase  in  the  amount  of  fat  normally 
present.  Randisi  (191 2)  recorded  a  successful  pyloroplasty  for  the 
removal  of  a  nut-sized  lipoma  which  had  given  rise  to  s^miptoms  of 
pyloric  stenosis.  It  is  to  the  larger  tumors,  which  may  more  justly  be 
recognized  as  neoplastic  in  character,  that  this  paragraph  has  special 
reference.  Such  cases  have  been  reported  by  Cruveilhier  (1835-42) 
(submucous);  Russdorf  (1867)  (12  cases  of  subserous  lipoma);  Virchow 
(1867)  (submucous);  Orth  (1887)  (subserous);  Murray  (1888)  (sub- 
serous); Tilger  (1893)  (2  cases  of  submucous  lipoma);  Fenwick  (1903) 
(submucous). 

Fischer  reported  (1905)  a  case  of  libro-lipoma  of  the  stomach  in  a 
woman  aged  37  years,  which  had  caused  pain  in  the  left  epigastpic  region 
for  about  a  month.  An  epigastric  hernia  developed,  but  there  was  no 
vomiting,  no  hemorrhage  and  no  indigestion.  The  left  rectus  was 
rigid,  and  a  diagnosis  was  made  of  recent  inflammatory  processes  in 
a  tumor  of  long  standing,  though  no  tumor  was  palpable.  Operation 
showed  the  hernia  to  be  an  epiplocele,  and  the  tumor  was  found  on  the 
lesser  curvature  of  the  stomach,  not  involving  the  mucous  membrane. 
It  was  successfully  resected;  and  microscopical  examination  showed  a 
fibro-lipoma,  with  acute  inflammation  and  hemorrhage  into  the  sub- 
stance of  the  tumor.  The  convalescence  was  delayed  by  five  attacks  of 
tetany  on  the  seventeenth  day  after  operation. 

In  none  of  these  patients,  except  Fischer's,  was  operation  under- 
taken ;  but  as  all  the  tumors  were  easily  enucleated  at  autopsy,  it  would 
be  perfectly  proper  to  attempt  their  removal  by  gastrotomy,  should 
their  presence  be  discovered  during  life. 

Myxoma. — According  to  Basch  (191 6)  only  three  cases  of  gastric 
myxomata  are  on  record,  including  that  reported  by  Hansemann  in 
1895.  They  are  properly  regarded  as  degenerated  forms  of  fibroma, 
etc. 

Cysts. — Cysts  are  found  in  the  stomach  either  as  retention  cysts 
of  the  mucous  glands,  or  as  the  result  of  traumatism  or  the  degeneration 
of  other  forms  of  tumor.     There  are  also  on  record  one  case  of  dermoid 


2  14        .         BEXIGX    TUMORS    OF    THE    STOMACH    AND    DUODENUM 

cyst  and  a  few  cases  of  hydatid  cysts.  The  dermoid  cyst  (Ruyschius, 
1737)  contained  hair,  teeth  attached  loosely  to  bone,  and  other  matters 
almost  too  wonderful  for  belief.  According  to  Femvick  (1903),  three 
of  the  hydatid  cysts  were  found  at  autopsy;  two  (Bochlendorf,  Barton) 
involved  the  stomach  in  the  course  of  their  development,  but  did  not 
originate  in  the  gastric  wall;  while  in  the  case  recorded  by  Castellvi  y 
Pallares  the  gastric  wall  seems  to  have  been  the  primary  seat  of  growth. 
A  fourth  case  of  hydatid  cyst  has  been  recorded  by  Hartmann  (1908); 
at  the  operation,  by  Dujarier,  the  cyst  was  found  to  have  developed 
between  the  mucous  and  muscular  coats  of  the  stomach;  it  was  succes- 
fully  excised.  Tuftier  (1908)  has  operated  on  a  patient  with  hydatid 
cyst  developing  in  the  gastro-hepatic  omentum,  and  thus  simulating 
a  tumor  of  the  lesser  curvature  of  the  stomach. 

Numerous  small  cysts  of  the  mucosa  are  frequently  seen  in  certain 
forms  of  gastritis.  They  are  true  retention  cysts,  the  inflammation 
obliterating  the  glandular  orifices — a  pathological  change  seen  to  an 
even  more  marked  degree  in  the  development  of  adenomata.  These 
small  retention  cysts  have  practically  no  surgical  interest,  unless  in 
connection  with  polyps  or  adenomata. 

Traumatic  cysts  of  the  stomach  are  very  rare.  Zeigler  (1894)  and 
Chutro  {1905)  have  each  successfully  operated  on  such  a  case.  As 
shown  in  Chutro's  valuable  contribution  to  the  literature  of  gastric 
cysts,  the  history  is  that  of  severe  traumatism  to  the  epigastric  and  left 
hypochondriac  regions.  Shock,  pain,  and  persistent  vomiting,  but 
without  evidences  of  peritoneal  infection,  are  the  immediate  symptoms. 
A  little  blood  may  be  vomited  or  passed  from  the  bowels.  After  a 
few  days  or  weeks,  the  more  acute  symptoms  subside,  though  vomiting 
may  persist;  and  the  physical  signs  are  more  accurately  localized  to  the 
stomach.  A  semi-fluctuating  tumor  may  form.  It  is  difficult  to  dis- 
tinguish this  from  an  encysted  peritonitis;  but  the  absence  of  suppura- 
tive signs  will  be  an  important  clue.  No  time  should  now  be  lost  in 
evacuating  the  contents  of  the  cyst  by  laparotomy;  suture  of  the  cyst  to 
the  parietal  peritoneum  and  drainage  eftected  a  cure  in  both  patients. 
The  cyst  forms  as  the  result  of  hemorrhage  into  the  subserous  (Zeigler) 
or  submucous  tissues  (Chutro),  aided  perhaps  by  the  eft'usion  of  gastric 
juice  from  the  deeper  portions  of  the  mucous  membrane,  which  in 
Chutro's  patient  was  intact.  The  cyst,  at  first  hemorrhagic,  soon 
becomes  serous  or  scro-purulent  in  character.  The  dangers  of  delay 
in  operating  arc:  (i)  Infection  of  the  cyst  from  stomach  contents;  (2) 
intraperitoneal  rupture  of  the  cyst,  causing  peritonitis;  (3)  rupture  of 
the  cyst  into  the  stomach,  creating  a  septic  perigastric  abscess.     Any 


GASEOUS    CYSTS  215 

of  these  events  may  be  responsible  for  death  in  patients  with  gastric 
cysts  not  of  traumatic  origin. 

More  frequent  are  cysts  which  occur  as  the  result  of  degeneration 
of  other  forms  of  tumors.  According  to  Virchow,  cyst  formation  is  a 
not  unusual  termination  of  fatty  tumors;  and  it  is  certainly  true  that 
most  of  the  gastric  cysts  reported  have  contained  fluid  resembling  dis- 
integrated blood  clot  and  fat.  The  large  cyst  surrounding  the  anterior 
wall  of  the  stomach,  found  post-mortem  by  Read  (1882)  appears  to 
have  originated  as  a  submucous  lipoma  which  afterward  underwent 
malignant  change;  while  the  remarkable  case  recorded  by  Hutchinson 
and  Sloane  (1856)  in  which  a  walnut  sized  cyst  was  found  at  autopsy, 
being  both  subserous  and  submucous,  and  its  two  sacs  communicating 
by  a  narrow  orifice  in  the  muscular  tunic,  was  possibly  also  of  the  same 
derivation,  the  contents  being  pinkish,  thick,  opaque,  and  glittering 
with  plates  of  cholesterine.  Albers  (1862)  observed  a  cyst  of  the  lesser 
curvature  at  autopsy  on  a  child.  Hebb  (1897)  and  Finnel  (1874) 
have  each  recorded  a  case  of  gastric  cyst  which  Fenwick  classes  as  serous. 
In  Hebb's  case  the  cyst  was  lined  with  epithelioid  cells,  and  may  there- 
fore have  been  lymphangeiomatous  in  origin.  Finnel's  patient  also 
had  carcinoma  of  the  pylorus.  Cases  in  which  a  probable  hemorrhagic 
origin  can  be  traced  have  been  reported  by  Rendu,  by  Gallois,  Hontang 
and  Leflaive  and  by  Anderson.  Some  of  these  so  called  hemorrhagic 
cysts  may  have  been  due  to  forgotten  injuries,  but  it  is  probable  that 
most  of  them  -were  degenerations  of  pre-existing  tumors.  In  the  case 
recorded  by  Fenwick  (1903)  this  origin  is  more  certain  in  view  of  the 
lymphangeiomatous  structure  which  is  mentioned.  A  true  lymphan- 
geiomatous cyst  has  been  reported  by  Engel-Reimers  (1879)  in  whose 
patient  the  presence  of  an  intensely  deforming  scar  near  the  lesser  curva- 
ture made  it  seem  hkely  that  the  subserous  cyst  of  lymphangeiomatous 
structure  was  not  a  true  neoplasm,  but  merely  a  retention  cyst  due  to 
the  obstruction  to  the  lymph  channels  by  the  cicatrix  already  described. 

There  remains  to  be  discussed  the  extremely  rare  affection  Gas- 
eous cysts."  This  disease,  well  known  to  the  veterinarian  from  its  fre- 
quent occurrence  in  swine,  has  been  studied  in  its  human  relation  by 
Hahn  (1899),  by  Holstein  (1899),  and  lately  by  Turnure'  (1913). 
According  to  the  former  authors  the  disease  was  first  noted  at  autopsy, 
in  1754,  by  Duvernoy.  Cloquet  in  1820  reported  a  case  of  gaseous 
cysts  (submucous  and  subserous)  of  the  stomach  and  intestines.  He 
had  also  observed  it  in  the  hog.  Mayer  in  1825  determined  that  the 
gas  in  these  cysts  was  composed  of  oxygen  and  nitrogen,  15.44  parts  of 
the  former  to  84.56  parts  of  the  latter.     Gaseous  cysts  of  the  vagina 


2l6  BENIGN   TUMORS   OF    THE    STOMACH    AND   DUODENUM 

and  of  the  bladder  have  also  been  noted.  Dupraz  in  1897  found  that 
the  gaseous  cysts  of  a  stomach  studied  by  him  were  dilatations  of  the 
l\Tnph  spaces,  and  that  they  were  accompanied  b}^  chronic  lymphangei- 
tis.  Three  theories  have  been  advanced  to  explain  the  development 
of  these  cysts:  the  mechanical,  which  assumes  a  leakage  of  gas  from 
the  lumen  of  the  gut  through  some  unperceived  channel  (the  cysts 
being  analagous  to  subcutaneous  emphysema) ;  the  bacterial,  which  has 
nothing  to  support  it  except  that  the  cysts  have  not  always  proved  to 
be  sterile;  and  the  neoplastic,  according  to  which  certain  degenerating 
cells  of  a  tumor  secrete  gas.  Hahn,  Jaboulay,  A'allas  and  Wendel 
have  operated  on  patients  with  gaseous  gastric  cj^sts.  Finney  in  1908 
published  a  paper  based  on  a  study  of  19  collected  cases  of  gaseous 
cysts  of  the  gastro-intestinal  tract;  and  Sloan  (1920)  refers  to  more 
than  50  cases  now  on  record.  Karsner,  in  Sloan's  paper,  supports  the 
theory  of  the  mechanical  origin  of  these  cysts,  from  some  minute  com- 
munication with  the  lumen  of  the  gastro-intestinal  tract. 

Operative  treatment  has  been  undertaken  in  the  following  cases  of 
gastric  cysts: 

1.  Rendu  (1880).     Hemorrhagic  cyst  aspirated  three  times,  and  finally 

drained  by  a  large  canula.     Death  from  peritonitis. 

2.  Gallois,  Hontang  and  Leflaive  (1884).     Hemorrhagic  cyst  punctured 

twice.  Death  after  many  months  from  intraperitoneal  rup- 
ture of  the  cyst. 

3.  Zeigler    (1894).     Traumatic  cyst  opened  and  drained.     Recovery. 

4.  Winands    (1895).     Intestine  punctured  for  obstruction.     True  con- 

dition found  five  years  later  at  autopsy. 

5.  Anderson  (1898).     Hemorrhagic  cyst  opened  and  drained.     Death  in 

24  hours  of  exhaustion. 

6.  Hahn  (1899).     Multiple  gaseous  cysts.     Excision  of  those  that  were 

pedunculated,  and  puncture  of  others.     Recovery. 

7.  Jaboulay   (1901)  explored  abdomen  of  patient  with  gaseous  cysts, 

did  pylorodiosis  by  Hahn's  method,  and,  believing  the  cysts 
were  due  to  some  low  grade  inflammatory  process  analogous 
to  tuberculosis,  closed  abdomen  without  drainage  and  with- 
out interfering  with  cysts.     Recovery. 

8.  Vallas  (1901).     Exploratory  operation  for  intestinal  obstruction  with 

peritonitis.  No  cause  found.  Abdomen  drained.  Death.  At 
autopsy  innumerable  subserous  and  submucous  gaseous  cysts 
of  stomach  and  intestines.  The  submucous  cysts  had  in  some 
olaces  caused  intestinal  obstruction. 


LYMPHADENOMA  2 I 7 

9.  Chuto  (1905).     Traumatic  cyst  opened  and  drained.     Recovery. 
10.  Wendel   (191 1)   successfully  enucleated  a  cyst  without  opening 
the  lumen  of  the  stomach;  examination  showed  the  large  cyst  to 
be  an  accessory  stomach  and  accessory  pancreas. 

Osteoma. — That  it  is  not  impossible  for  a  gastric  tumor  to  undergo 
osteoid  transformation  is  proved  by  the  unique  case  reported  by  Web- 
ster (1827).  He  found  at  autopsy  on  a  patient  who  had  died  with 
symptoms  of  intestinal  obstruction,  that  the  pylorus  was  plugged  as 
with  a  cork  by  a  cartilaginous  tumor,  with  numerous  spicules  of  bone, 
which  was  adherent  to  the  gastric  wall  near  the  pyloric  orifice. 

Concretions  have  been  found  in  the  stomach  occasionally.  They 
are  generally  due  to  the  long  continued  use  of  mineral  substances  (bis- 
muth, etc.)  as  medicines.  Fenwick  (1902)  refers  to  four  instances 
in  which  such  concretions  were  composed  of  shellac  or  varnish.  Hallas 
(1914)  describes  two  further  cases  of  shellac  concretions  in  the  stomach, 
discovered  at  autopsy.  Both  patients  were  inebriates  and  were 
accustomed  to  drinking  furniture  polish  for  the  sake  of  the  alcohol  it 
contained.  In  the  museum  of  the  Academy  of  Natural  Sciences  of 
Philadelphia  there  is  a  remarkable  specimen  of  a  large  gastrolith  from 
a  horse,  deposited  by  Dr.  John  Ashhurst,  Jr. 

Angeioma. — ^Lammers  (1893)  reported  a  case  of  simple  angeioma 
of  the  stomach,  found  at  autopsy;  there  had  been  no  gastric  symptoms 
during  hfe.  Stokis  (1905)  at  the  autopsy  on  a  twelve  day  old  infant, 
who  died  in  convulsions  after  profuse  hematemesis  and  melena,  found 
a  capillary  angeioma,  in  the  submucous  and  muscular  tissue  of  the 
stomach  near  the  cardia,  which  was  proved  to  be  the  source  of  the 
hemorrhage.  Guisez  (1913)  detected  an  angeioma  of  the  cardia  by 
means  of  the  esophagoscope.  Treatment  by  dilatation  followed 
by  radium  resulted  in  a  complete  cure.  In  connection  with  sarcoma 
and  myoma  angeiomatous  changes  are  not  unusual. 

L3rmphadenoma. — Gilly  collected  in  1886  51  cases  of  gastro- 
intestinal lymphadenoma,  the  stomach  being  involved  in  14  instances. 
A  few  cases  have  been  recorded  since.  In  all  known  cases,  lymphoma- 
tous  growths  have  been  observed  in  other  parts  of  the  body  as  well — in 
the  spleen,  lymph  nodes,  bones,  pharynx,  or  intestines.  In  all  cases  of 
gastric  lymphadenoma,  the  intestines  were  involved.  This  affec- 
tion arises  either  in  the  subserous  or  submucous  lymphatic  tissues  of  the 
stomach.  In  the  submucous  tissues  it  exists  either  as  a  locahzed  or 
diffused  form,  usually  manifesting  itself  on  the  surface  of  the  stomach  by 
a  polypoid  condition   of  the  mucosa.     Ulceration  is  more  usual  in 


2l8  BENIGN    TUMORS    OF    THE    STOMACH    AND    DUODENUM 

the  circumscribed  form.  The  tumors  which  arise  in  the  submucous 
tissues  rarely  cause  obstruction,  but  those  commencing  in  the  subserous 
tissue,  and  which  are  usually  ditTuse,  frequently  penetrate,  paralyse, 
and  ultimately  destroy  the  muscular  coat,  producing  dilatation  of  the 
stomach  and  consequent  stagnation  of  food.  In  some  cases  it  appears 
to  have  been  demonstrated  that  the  disease  originated  in  the  neighbor- 
ing mesenteric  lymph  nodes,  and  subsequently  involved  the  subserous 
lymphatic  structures  of  the  stomach. 

Hodgkin's  Disease,  affecting  the  stomach,  deserves  passing  men- 
tion. In  a  case  recorded  by  Scott  and  Forman  (1916),  no  other  region 
of  the  body  was  affected.  A  section  of  the  stomach  was  removed  at 
operation  for  study,  and  found  to  be  histologically  typical.  The 
patient,  a  man  aged  53  years,  died  two  days  after  the  exploratory 
laporatomy.  about  one  year  after  the  first  symptoms  of  gastric  disease. 

Plastic  Linitis. — This  term  was  used  by  Brinton  (1859)  to  describe 
a  disease  which  had  been  previously  studied,  but  had  not  been  named, 
by  Andral.  It  is  an  affection  characterized  pathologically  as  a  dift'use 
sclerosis  of  the  stomach,  involving  especially  the  submucous  tissues, 
and  accompanied  by  marked  thickening  of  the  gastric  walls,  and  by  a 
diminution  in  the  capacity  of  the  stomach.  The  process  usually 
commences  in  the  pyloric  region,  and  gradually  spreads,  without 
affecting  the  mucous  membrane,  until  the  entire  wall  of  the  stomach 
becomes  thickened  and  rigid,  and  its  lumen  much  diminished  in  size. 
There  have  been  man}-  other  synonymous  terms  employed  to  describe 
the  same  condition.  Among  the  best  known  are:  Cirrhosis  or  Fib- 
romatosis of  the  Stomach;  Leather-bottle  Stomach;  Zuckergussmagen ; 
Submucous  Sclerosis;  Endogastritis  Obliterans;  Magenschrumpfung; 
etc.  The  causes  to  which  this  pathological  change  have  been  attri- 
buted are  many.  Carcinoma  and  syphilis  sometimes  produce  a  pro- 
fuse gastric  infiltration  which  even  microscopically  is  distinguishable 
from  this  affection  only  with  the  greatest  difficulty.  Some  cases  of 
hyperemesis  lactantium  seem  to  be  caused  by  an  identical  submucous 
sclerosis.  Plastic  linitis  is  usually  regarded  as  benign,  and  is  considered 
by  most  of  those  who  have  given  most  attention  to  the  subject  a 
special  disease  entitj-.  The  best  articles  recently  published  are  those 
of  Jonnesco  and  Grossman  (1908),  Kurt  von  Sury  (1907)  and  Thomson 
and  Graham  (1913).  Kurt  von  Sury  concluded  that  cirrhosis  of  the 
stomach  is  due  to  the  same  cause  as  polyserositis,  namely  chronic 
passive  hyperemia  from  cardiac  insufficiency.  Jonnesco  and  Gross- 
man believe  that  it  is  simply  a  chronic  inflammator\-  change,  and  in  no 
way  neoplastic  in  character.     Thomson  and  Graham,  from  their  study 


PLASTIC    LTNITIS 


219 


of  50  specimens,  conclude  that  it  is  a  disease  siii  generis,  chronic  inflam- 
matory in  nature,  caused  by  ulceration  or  by  ulcer,  and  frequently 
overgrown'  by  carcinoma.  Histologically  it  appears  to  be  nearly 
related  to  the  lymphadenomatous  changes  just  described.  Its  con- 
nection with  chronic  obstruction  of  the  efferent  lymph  vessels  of  the 
stomach  does  not  appear  to  have  received  sufficient  attention.  Its 
relations  with  endothelioma  and  sarcoma  are  not  clear. 

By  microscopical  examination  it  is  sometimes  impossible  to  say 
whether  the  epithelioid  cell  nests  which  infiltrate  the  submucous  and 


/ 


\; 


Fig.  61. — Total  Contraction  of  the  Stomach   (Magenschrumpfung)  from  Plastic  Linitis. 
Natural  Size.      Prom  a  Specimen  in  the  Museum  of  the  Lankenau  Hospital. 


muscular  tissues  are  really  epithelial  in  derivation  (carcinoma),  or 
due  to  proliferation  of  previously  existing  endothelial  cells  lining  the 
IvTnph  channels  which  normally  exist  in  these  situations  (see  Jaboulay's 
case  (1905)  of  subtotal  gastrectomy  for  an  infiltrating  growth  thought 
by  Gayet  and  Patel  to  be  epitheliomatous).  Porter  (191 5)  quotes 
W.  J.  Mayo  as  stating  that  "they  have  had  in  their  clinic  perhaps  20 
cases  of  so-called  leather-bottle  stomach,  and  all  those  they  have  been 
able  to  excise  and  make  sections  of  proved  to  be  malignant  although 
sometimes  many  sections  had  to  be  cut  before  a  malignant  area  was 
found." 

.\s  the  question  of  the  pathology  of  this  affection  is  still  suh  jiidice, 
it  is  probably  safer  at  present  to  regard  it  as  a  pathological  change 


220  BENIGN   TUMORS    OF    THE    STOMACH   AND   DUODENUM 

which  may  arise  in  several  different  conditions — ulcer,  carcinoma, 
syphilis,  polyserositis,  honphatic  obstruction,  etc. 

Treatment  must  usually  be  palliative.  Should  the  change  be 
recognized  early  enough,  partial  or  subtotal  gastrectomy  should  be 
attempted.  In  a  somewhat  similar  case  Sheldon  (1906)  did  gastro- 
jejuiioslomy,  and  reported  his  patient  in  good  health  three  years  and 
a  half  later.  If  the  disease  has  progressed  so  far  as  practically  to 
obliterate  the  cavity  of  the  entire  stomach,  duodenostomy  should  be 
done;  or  if  the  disease  has  invaded  the  duodenum,  jejunostomy  may 
be  the  last  resort.  This  operation  was  adopted  in  one  case  of  this 
disease  by  v.  Eiselsberg  (1908),  with  gratifying  result,  the  patient 
still  using  the  fistula  with  comfort  five  years  after  the  operation.  We 
have  found  it  impossible  to  collect  reliable  stastistics  as  to  operations 
for  this  condition,  as  many  surgeons  report  as  instances  of  plastic 
limits  any  cases  of  gastric  carcinoma  in  which  the  stomach  walls  are 
much  thickened. 

The  senior  author  has  had  under  his  care  sLx  patients  with  diffuse 
fibrosis  of  the  stomach  clinically  resembhng  plastic  linitis.  The 
history  of  one  patient  is  as  follows : 

Frank  K.  aged  46  years.  Two  uncles  died  of  phthisis.  When  22  years  of  age  the 
patient  was  accidentally  inoculated  with  syphilis,  developing  a  chancre  on  the  thumb.  Re- 
ceived antisyphilitic  treatment  for  2  years.  In  1903,  three  years  before  his  admission  to  the 
German  (now  Lankenau)  Hospital,  he  had  an  attack  of  pyelitis,  after  the  passage  of  a 
urethral  sound.  Following  this  illness  he  suffered  from  acute  gastritis,  having  hiccoughed 
for  II  days.  For  the  last  2  years  has  suffered  from  pain  and  tenderness  in  the  epigas- 
trium. He  vomited  only  when  he  forced  himself,  and  then  brought  up  food  taken  one  or 
two  days  previously.  No  hematemesis  or  melena.  For  past  7  months  no  food  but  milk. 
Has  lost  loo  lbs.  in  weight.  Says  he  cannot  retain  more  than  6  oz.  in  his  stomach  at  one 
time.  Physical  examination  was  negative  except  for  tenderness  and  rigidity  in  the  epi- 
gastric region.  Examination  of  stomach  contents  showed:  total  acidity,  10;  no  free  hydro- 
chloric acid;  no  lactic  acid;  no  Oppler-Boas  bacilli.  Bloodcount:  R.  B.  C,  3,410,000; 
W.  B.  C,  8,000;  Hb.,  62  per  cent.;  color  index  o.S. 

Operation  June  3,  1906.  The  stomach  was  found  much  contracted,  its  walls  dense 
and  fibrous,  and  resembling  in  appearance  and  shape  the  small  bowel.  Posterior  gastro- 
jejunostomy was  done,  the  gastric  wall  being  an  inch  in  thickness.  Recover}'  was  un- 
eventful, and  the  patient  remained  in  good  health  for  2  J^  years  after  the  operation,  but  has 
since  died,  of  unknown  cause. 

In  five  Other  cases  the  operation  consisted  merely  in  exploration, 
the  stomach's  condition  not  warranting  any  operative  relief.  One  of 
these  patients  was  later  operated  on  in  another  citj-,  a  jejunal  fistula 
being  established;  after  death,  which  occurred  a  few  weeks  subsequently, 
the  lesion  was  proved  to  be  carcinomatous. 


CHAPTER  X 

MISCELLANEOUS  AFFECTIONS  OF  THE  STOMACH  AND 

DUODENUM 

Tuberculosis  of  the  Stomach  is  rare.  Broders  (19 17),  in  his  ad- 
mirable review  of  the  subject,  reached  the  conclusion  there  were  only 
49  positive  cases  on  record,  118  probable  cases;  while  he  classed  59 
of  the  cases  reported  as  such  as  "doubtful,"  and  entirely  rejected  80  of 
the  reported  cases.  According  to  Curschmann  (1904),  in  900  autopsies 
on  tuberculous  subjects  Durk  found  the  stomach  involved  only  in  4 
cases;  and  in  2000  autopsies  Simmonds  found  only  8  tuberculous 
ulcers  of  the  stomach;  while  Glaubitt,  according  to  Barchasch,  noted 
47  tuberculous  ulcers  in  autopsies  on  2237  tuberculous  patients.  Goss- 
mann  (1912)  reports  18  cases  of  ulcerative  gastric  tuberculosis  among 
5900  autopsies,  or  0.31  per  cent,  of  the  total  autopsies,  and  0.76  per 
cent,  of  those  (2360)  which  showed  tuberculosis  in  any  situation. 
Adler  (1907)  found  11  cases  of  tuberculous  gastric  ulcer  in  839  autop- 
sies on  tuberculous  children;  which  makes  it  appear  rather  less  unusual 
in  children  than  in  adults. 

According  to  Ricard  and  Chevrier  (1905),  Louis,  in  1825,  first 
recognized  tuberculosis  of  the  stomach;  but  Hattute  (1874)  was  the 
earliest  to  note  pyloric  stenosis  from  tuberculosis;  and  it  was  not 
until  1894  that  the  subject  was  brought  prominently  before  the  pro- 
fession by  Durante. 

It  is  important,  in  the  first  place,  to  distinguish  between  gastric 
ulcers  occurring  in  tuberculous  patients,  and  those  ulcers  due  to  the 
local  action  of  the  tubercle  bacillus.  The  former  may  be  of  the 
ordinary  type  ("  round,"  "  acute,"  "  chronic,"  etc.)  or  in  some  instances 
may  be  due  to  the  toxemia  of  tuberculosis  localized  in  other  parts, 
the  ulcers  thus  resembling  in  origin  those  erosions  on  which  Dieulafoy 
and  more  recently  his  pupil  Gandy  have  laid  such  stress,  as  caused  by 
the  toxemia  of  various  infectious  diseases.  If  the  toxemia  of  tubercu- 
losis give  rise  to  mucous  erosions  in  the  stomach,  these  erosions  may 
later  become  infected  with  the  tubercle  bacillus,  either  ingested  with 
food,  or  swallowed  with  the  sputum.  Or  a  true  tuberculous  ulcer  may 
possibly  arise  de  novo,  without  the  previous  existence  of  an  erosion  or 
an  open  ulcer.  Secondary  infection  of  an  already  existing  gastric 
lesion  is  probably  much  the  more  frequent  origin.     The  portal  of 


222    MISCELLANEOUS    AFFECTIONS    OF    THE    STOMACH    AND    DUODENUM 

entry  is  usually  thrt)ugh  the  gastric  mucous  membrane,  from  the  cavity 
of  the  stomach;  though  infection  by  the  blood  and  lymph  streams  is 
also  recognized  as  possible.  The  rarity  of  the  affection  is  no  doubt 
due  to  the  short  time  that  the  ingesta  normally  remain  in  the  stomach, 
as  well  as  to  the  antiseptic  action  of  the  gastric  juice.  Certainly  intes- 
tinal tuberculosis  is  much  more  frequent  than  is  gastric  (Barchasch 
says  the  intestines  are  inv'olved  in  from  47  to  6.3  per  cent,  of  phthisical 
patients  who  come  to  autopsy) ;  and  gastric  tuberculosis  when  it  does 
occur  is  in  the  immense  majority  of  cases  secondary  to  some  tubercu- 
lous lesion  in  other  parts  of  the  body,  particularly  the  lungs  or  bron- 
chial lymph  nodes.  According  to  Van  X'alzah  and  Xisbet.  "  sometimes 
the  only  detectable  local  lesion  is  tubercle  of  the  choroid  or  a  laryngeal, 
or  nasal  ulcer."  They  also  remind  the  reader  that  the  tubercle  bacillus 
may  be  found  in  the  urine  when  it  is  absent  from  the  sputum.  Barch- 
asch (1907)  admitted  six  cases  as  examples  of  undoubte  primary  tuber- 
culosis of  the  stomach  but  Broders  (1Q17)  claims  no  case  can  be 
recognized  as  primary  in  the  stomach  if  there  are  tuberculous  lesions 
in  any  other  part  of  the  body;  and  states  that  no  case  so  far  reported 
meets  this  requirement. 

The  tubercle  bacillus  may  pass  through  the  gastric  mucosa,  leaving 
it  intact,  and  lodge  and  proliferate  in  the  neighboring  lymph  nodes. 
This  is  \"ery  unusual.  When  the  lymjjh  nodes  have  been  long  involved, 
whether  primarily  or  secondarily  diseased,  they  become  caseous  and 
sometimes  calcareous.  Those  along  the  lesser  curxature  may  soften 
and  rupture  into  the  cavity  of  the  stomach;  but  at  the  pylorus  the 
thickness  of  the  wall  is  so  great  as  to  prevent  this  termination.  Peri- 
pyloric tuberculous  lymphatic  involvement  is  sometimes  a  cause  of 
pyloric  stenosis  without  lesions  of  the  gastric  mucous  membrane. 

Poncet  and  Leriche  (1908)  distinguish  three  main  forms  of  surgical 
tuberculosis  of  the  stomach:  an  ulcerated  form,  which  is  rendered 
surgical  only  by  its  complications;  an  hypertrophic  form,  the  gastric 
tuberculoma,  simulating  carcinoma;  and  fmally  an  inllammatory 
form,  which  differs  from  other  forms  of  gastritis  only  in  its  etiology. 

Gastric  tuberculosis  is  almost  always  ulcerated.  The  disease 
affects  by  preference  the  submucous  and  subserous  tissues,  the  muscu- 
lar tunic  escaping  as  a  rule.  But  in  the  pyloric  region,  where  the 
disease  usually  assumes  the  hyperplastic  form,  the  muscular  coat  is 
jjrone  to  invasion.  In  the  body  of  the  stomach  tuberculosis  is  usually 
diffuse.  The  ulcers  are  ragged,  undermined,  leaxing  free  oxerhanging 
edges  of  mucosa;  and  when  of  long  duration  are  seated  on  characteristic 
raised  and   thickened   bases,   called   by   the  French  "  rem  parts."     The 


TUBERCULOSIS  223 

ulcer  often  assumes  the  transverse  character,  parallel  with  the  blood 
vessels,  as  are  the  similar  ulcers  of  the  intestine.  Perigastritis  usually 
occurs  in  time  to  protect  against  perforation  into  the  abdominal  cavity; 
and  hemorrhage  also  is  rare.  In  some  cases  the  duodenum  has  been 
opened  by  ulceration,  forming  a  gastro-duodenal  fistula.  This  may 
temporarily  relieve  the  symptoms  of  pyloric  stenosis.  The  colon 
has  also  been  penetrated  by  the  ulceration  of  a  tuberculous  gastric 
ulcer.  Perforation  of  the  esophagus  by  a  tuberculous  ulcer  was  the 
cause  of  death  in  a  patient  of  Giorgi,  who  was  found  at  autopsy  also 
to  have  had  tuberculous  ulcers  of  the  stomach. 

Among  the  107  cases  of  gastric  tuberculosis  studied  by  Ricard  and 
Chevrier  there  were  only  three  in  which  no  other  portion  of  the  digest- 
ive tract  was  involved  in  tuberculous  disease.  The  small  intestine, 
the  mesenteric  lymph-nodes,  and  the  cecum  arc  oftenest  affected. 

The  symptoms  are  those  of  gastric  ulcer.  Perforation  also  is 
rare:  Ricard  and  Chevrier  (1905)  report  one  case,  as  do  Renon  and 
Verliac  (1907);  both  patients  died.  Pyloric  stenosis  from  tuberculous 
hyperplasia  is  one  of  the  usual  forms  of  the  disease.  When  present, 
it  is  not  difficult  to  detect  the  stenosis,  by  the  usual  symptoms  and 
physical  signs;  but  it  is  only  by  a  searching  examination  for  tul)erculous' 
lesions  elsewhere  in  the  body  that  the  etiological  diagnosis  of  the 
gastric  lesion  can  be  made.  The  tuberculin  test  may  aid  in  determining 
the  question.  At  operation  it  may  be  difficult  to  distinguish  these 
cases  from  those  of  pyloric  carcinoma.  Tuberculosis  is  less  unusual 
in  those  under  30  years  of  age.  Inflammatory  hyperplasia,  plastic 
linitis,  and  even  syphilis  have  to  be  considered. 

The  prognosis,  so  long  as  there  is  no  pyloric  stenosis,  depends 
rather  upon  the  other  tuberculous  lesions  in  the  body  than  upon  those 
in  the  stomach.  If  pyloric  stenosis  is  present,  the  prognosis  is  ab- 
solutely bad,  without  operation. 

The  operative  treatment  of  gastric  tuberculosis  has  so  far  ac- 
complished little  beyond  relieving  the  most  distressing  symptoms 
and  moderately  prolonging  life.  Zesas  (19 13)  refers  to  8  gastrectomies, 
with  4  deaths;  and  among  23  gastro-jejunostomies  to  which  we  have 
reference  there  were  4  more  or  less  immediate  deaths,  9  patients  who 
recovered  temporarily  but  died  within  a  few  months  either  from  local  or 
general  tuberculosis,  and  only  10  who  recovered  and  lived  long  enough 
to  profit  from  the  operation.  One  patient  survived  for  three  and  one- 
half  years  after  gastro-jejunostomy  and  then  died  from  an  abscess  of  the 
liver,  the  exact  cause  of  which  could  not  be  determined  at  autopsy 
(Chevassu,  cited  by  Ricard  and  Chevrier,  1905). 


2  24   MISCELLANEOUS  AFFECTIONS  OF  THE  STOMACH  AND  DUODENUM 

Operation  is  not  advisable  except  to  relieve  pyloric  obstruction. 
If  it  can  be  determined  that  other  tuberculous  lesions  in  the  body 
are  not  such  as  to  render  the  expectation  of  life  unreasonably  limited, 
it  may  be  proper  in  selected  cases  to  undertake  exploratory  laparo- 
tomy with  a  view  to  prolonging  life  by  improving  nutrition  through 
the  means  of  some  palliative  operation.  Ricard  and  Chevrier  se- 
verely condemn  all  attempts  at  excision  as  futile  and  extremely  liable 
to  disseminate  the  tuberculous  process.  If,  however,  the  disease 
is  limited  to  the  pylorus,  and  especially  if  the  tuberculosis  appears  pri- 
mary in  the  stomach,  partial  gastrectomy  should  be  preferred.  In  other 
cases  the  nature  of  the  operation  will  depend  upon  the  local  conditions 
and  upon  the  extent  of  constitutional  in\olvement.  Gastrolysis  may 
be  sufficient  when  the  pyloric  obstruction  is  caused  by  perigastric 
tuberculous  peritonitis.  In  most  cases  gastro-jejunostomy  is  the 
operation  of  choice.  In  some  patients  pyloroplasty  may  give  satis- 
factory results. 

Syphilis  of  the  Stomach. — It  has  been  said  that  the  stomach  is 
affected  in  about  one  per  cent,  of  syphilitic  patients.  Among  243 
autopsies  which  showed  unmistakable  lesions  of  syphilis,  Chiari  found 
(1891)  syphlitic  lesions  of  the  stomach  in  three  cases.  Morgan  (1915) 
reports  that  by  employing  the  Wassermann  test  in  all  patients,  com- 
plaining of  severe  gastric  symptoms  he  found  only  i  per  cent,  infected 
with  syphilis.  In  a  series  of  7545  gastric  cases  Smithies  (191 5)  found 
1.6  per  cent,  had  syphilitic  lesions  of  the  stomach.  In  1898  Flexner 
was  able  to  collect  only  fifteen  authentic  instances  of  gastric  syphilis, 
including  one  of  his  own.  During  the  last  two  decades  the  attention 
of  surgeons  as  well  as  physicians  has  been  more  particularly  directed  to 
the  stomach,  and  numerous  other  observations  have  been  published, 
there  being  now  on  record  probably  about  one  hundred  cases  of  gastric 
syphilis. 

As  in  the  case  of  tuberculosis  it  is  important  to  distinguish  ordinary 
ulcers  of  the  stomach  occurring  in  syphilitic  persons,  from  gastric 
lesions  primarily  due  to  the  syphilitic  virus.  In  determining  the 
true  nature  of  the  lesion,  the  microscopical  appearances  are  a  surer  test 
than  is  the  result  of  specific  treatment.  There  is  very  good  reason  to 
believe  that  anti-syphilitic  treatment  will  favorably  influence  the 
course  of  non-specific  gastric  lesions  in  syphilitic  subjects,  by  improv- 
ing the  general  health;  and  therefore  it  should  not  be  assumed  that  the 
gastric  lesions  are  specific  merely  because  a  course  of  mercurials  or 
iodides  prescribed  for  a  syphilitic  patient  is  followed  by  subsidence  of 
the  gastric  symptoms.     Yet  it  must  also  be  remembered  that  in  the 


SYPHILIS  225 

interpretation  of  histological  appearances  even  professed  pathologists 
are  not  always  in  accord,  and  that  this  is  particularly  the  case  with 
syphilitic  as  well  as  with  cancerous  lesions. 

Syphilis  affects  the  stomach  either  as  a  diffuse  infiltration,  invading 
especially  the  submucous  tissues,  or  as  a  distinct  tumor,  a  syphiloma 
or  gumma.  In  either  case  the  lesions  are  prone  to  ulcerate,  as  a  result 
of  the  endarteritis  and  consequent  interference  with  the  nutrition  of 
the  overlying  mucosa.  Yet  hemorrhage,  unless  occult,  is  an  infrequent 
sign.  In  Flexner's  patient,  whose  stomach  was  the  seat  of  an  ulcerated 
submucous  gummatous  infiltration,  death  occurred  from  perforative 
peritonitis.  In  other  cases,  stricture  may  result.  More  common  as  a 
cause  of  obstruction  is  the  localized  syphiloma.  Bird  (1907)  claimed 
to  have  observed  12  cases  of  gastric  syphiloma,  the  pylorus  being  the 
the  seat  of  the  tumor  in  11  of  the  patients.  Downes  and  LeWald 
(1915)  who  studied  8  cases  in  which,  in  the  course  of  two  years,  the 
diagnosis  of  syphilis  of  the  stomach  was  made  with  a  fair  degree  of 
certainty,  lay  stress  on  the  constanc}'  of  the  pain,  which  they  describe  as 
gnawing  in  character,  and  which  is  opposed  to  the  periodicity  of  the 
painful  attacks  of  simple  gastric  ulcer.  They  regard  a  rather  dumb- 
bell shaped  hour-glass  stomach  as  revealed  by  the  X-ray  as  typical  of 
syphilitic  disease. 

SyphiUtic  gastritis,  in  which  there  may  be  no  specific  lesions  of  the 
stomach,  is  a  fairly  frequent  accompaniment  of  the  disease.  It  is 
often  encountered  in  patients  with  hereditary  syphilis.  It  is  sometimes 
caused  by  anti-syphilitic  treatment. 

The  diagnosis  of  gastric  syphilis  rests  on  three  points:  first,  the  his- 
tory of  syphilis  in  the  individual  patient  or  the  presence  of  a  positive 
Wassermann  reaction;  second,  the  resistance  of  the  gastric  symptoms 
to  all  ordinary  remedies;  and  thir.d,  the  rapid  amelioration  under 
specific  treatment.  But  even  though  all  three  of  these  postulates 
be  fulfilled,  the  gastric  lesions  may  not  be  due  to  a  local  manifestation 
of  the  syphilitic  virus;  and  even  though  one  or  more  of  these  factors 
be  wanting,  the  lesions  of  the  stomach  may  yet  be  syphilitic. 

Operative  treatment  is  demanded  only  when  one  of  the  gastric  ori- 
fices is  obstructed  by  a  syphiloma  which  is  unaffected  by  specific  treat- 
ment. Morgan  (1906)  reported  the  case  of  a  patient  who  had  suffered 
for  four  years  from  anorexia,  flatulence,  thirst,  and  dilated  stomach  with 
pyloric  obstruction;  these  symptoms  were  attended  by  loss  of  weight, 
progressive  emaciation,   and   finally  the  development  of    a    palpable 


226   MISCELLANEOUS  AFFECTIONS  OF  THE  STOMACH  AND  DUODENUM 

mass  in  the  pyloric  region.  As  sj-philis  was  denied,  a  diagnosis  of 
carcinoma  was  made;  but  the  patient  finally  acknowledged  having 
having  had  a  chancre,  followed  by  secondary  lesions,  four  years  pre- 
\'iously.  Iodide  of  potash  was  administered,  the  sjinptoms  were 
promptly  relieved,  and  health  was  restored.  Tuffier  in  1899  did  gastro- 
jejunostomy in  a  syphihtic  negro,  whose  pylorus  was  obstructed 
by  a  large,  firm,  elastic  tumor  which  disappeared  four  months  after  the 
operation.  In  the  series  of  8  cases  reported  by  Downes  and  LeWald, 
gastro-jejunostomy  was  done  in  5  because  of  obstruction.  The  3 
patients  without  obstruction  were  rapidly  relieved  by  anti-SN-philitic 
treatment.  It  is  only  rarely  that  excision  is  to  be  undertaken.  If 
any  operation  is  requisite  to  aid  medicinal  treatment,  some  palliative 
procedure  is  to  be  preferred:  gastro-jejunostomy  for  pyloric  stenosis 
and  gastrostomy  for  obstruction  of  the  cardiac  orifice.  Of  course  if 
the  tumor  is  possibly,  malignant,  and  is  operable  excision  should  be 
done.  Bird  and  others  lay  much  stress  on  the  hepatic  and  peritoneal 
involvement  as  characteristic  of  syphilis ;  Bird  considers  of  importance 
the  presence  of  "bluish  striae  following  the  course  of  the  hTnphatics, 
or  of  splotches  of  opaque  bluish  white  on  the  serosa  or  starred  cicatrices 
with  strongly  fibrous  or  even  calcareous  centers."  Hausmann  (1911) 
thinks  fijced  pyloric  tumors  that  do  not  cause  stenosis  should  make  one 
suspect  syphilis  especially  if  the  diseased  area  is  dilated  rather  than 
contracted. 

Unless  there  is  very  good  reason  to  suspect  a  s>T)hilitic  origin  for 
the  gastric  symptoms,  the  surgeon  will  best  consult  the  interests  of 
his  patient  by  not  delaying  too  long  an  operation  which  is  clearly 
indicated,  for  the  sake  of  trying  the  effect  of  anti-syphilitic  remedies. 
He  should  bear  in  mind,  moreover,  that  sjTnptoms  of  gastric  distress 
in  a  sj'phihtic  patient  are  frequently  caused  by  the  ingestion  of  anti- 
sj^hilitic  remedies;  and  should  such  a  cause  for  the  sjonptoms  be 
probable,  these  remedies  should  be  discontinued  temporarily.  On  the 
other  hand,  should  the  s}'philitic  origin  of  the  gastric  lesions  become 
manifest  by  operation  or  otherwise,  no  time  should  be  lost  in  getting 
the  patient  under  the  influence  of  mercury  and  the  iodides :  such  treat- 
ment will  be  an  important  adjuvant  to  any  operation  that  shall  have 
been  performed.  Permanent  cure,  however,  as  noted  by  Smithies 
(1915),  can  hardly  be  promised,  as  the  gastric  sjTnptoms  show  a  per- 
sistent tendency  to  return  even  after  long  periods  of  latency. 


PHLEGMONOUS   GASTRITIS  22? 

We  have  references  to  the  following  operations  for  syphilitic  lesions 
of  the  stomach: 

Operation  Cases  Deaths 

Exploratory 5  o 

Gastro-jejunostomy 11  3' 

Partial  gastrectomy 7  o 

Phlegmonous  Gastritis. — Phlegmonous  gastritis  is  a  rare  form 
of  inflammation  of  the  stomach,  which  has  been  recognized,  according 
to  Schnarrwyler  (1906),  since  1656,  when  a  case  was  first  observed  by  P. 
Borel.  Jensen  (191 1)  collected  431  cases  of  the  condition.  It  has  been 
described  under  a  multitude  of  names,  which  are  given  at  length  by 
Leith  (1896),  and  of  which  the  most  frequently  emploj'ed  are  "sub- 
mucous gastritis"  and  "suppurative  linitis." 

The  disease  is  defined  by  Schnarrwyler  as  a  "diffuse  purulent 
inflammation  of  the  stomach,  which  has  its  chief  seat  in  the  sub- 
mucosa,  but  which  may  later  produce  a  lymphy  and  finally  purulent 
infiltration  of  the  intermuscular  connective  tissue,  and  thus  even- 
tually reach  the  serosa;  while  on  the  other  hand  the  overlying  mucosa 
becomes  infiltiated  with  pus  cells  and  swollen." 

Robson  and  Moynihan,  in  their  work  on  Diseases  of  the  Stomach 
(1904),  went  into  the  pathology  and  symptoms  in  considerable  detail, 
and  little  can  be  added  to  what  they  then  wrote.  According  to  the 
definition  given  above,  only  diffuse  submucous  inflammations  should 
be  included;  but  as  there  is  no  doubt  that  well  localized  phlegmons  of 
the  gastric  wall  are  occasionally  encountered,  it  seems  scarcely  worth 
while  to  make  a  separate  classification  for  "phlegmon  ventricuK,"  and 
we  therefore  agree  with  Robson  and  Moynihan,  who  describe  phleg- 
monous gastritis  as  existing  in  two  forms,  the  circumscribed  and  the 
diffuse. 

Although  there  seems  good  reason  to  beheve  that  the  disease 
occasionally  arises  without  any  macroscopical  lesion  of  the  gastric 
mucosa,  it  is  more  frequently  encountered  as  a  complication  of  gas- 
tric ulcer,  or  a  sequel  to  some  operation  on  a  stomach  which  is  already 
the  seat  of  catarrhal  gastritis.  The  streptococci  are  the  micro-organ- 
isms most  often  found;  but  staphylococci,  colon  bacilU,  and  even 
gas  bacilh,  have  been  recovered  from  the  stomach  in  some  instances. 

Operations  have  proved  the  exciting  cause  in  cases  recorded  by 
Schnariwyler,  Eiselsberg,  Page,  and  others.     In  Schnarrwyler' s  patient 
'  Two  deaths  occurred  several  weeks  after  operation. 


228    MISCELLANEOUS  AFFECTIONS  OF  THE  STOMACH  AND  DUODENUM 

an  anterior  gastro-jejunostomy  had  been  done  by  Hildebrand  for  an 
inoperable  mass  obstructing  the  pylorus.  Death  followed  in  five  days; 
and  the  autopsy  showed  that  it  was  caused  by  a  diffuse  sero-purulent 
peritonitis  arising  in  a  purulent  infiltration  of  the  stomach  walls,  which 
had  not  been  present  at  the  time  the  operation  was  done.  In  v.  Eisels- 
berg's  patient  death  from  phlegmonous  gastritis  followed  six  days  after 
he  did  "gastro-enterostomia  retrocolica  anterior;"  and  in  a  patient 
operated  on  by  Page,  fatal  phlegmonous  gastritis  followed  the  per- 
formance of  gastrostomy  for  stricture  of  the  esophagus. 

The  clinical  picture  presented  by  a  patient  with  diffuse  phleg- 
monous gastritis  is  thus  graphically  summarized  by  Robson  and  Moy- 
nihan:  It  is  that  "of  a  patient  acutely  ill  from  some  febrile  disease,  with 
irregular  elevations  of  temperature,  very  feeble  and  rapid  pulse,  vomit- 
ing, constant  pain  in  the  abdomen,  referred  generally  to  the  epigastrium, 
and  slight  tenderness  on  deep  palpation.  It  is  therefore,"  they  pro- 
ceed, "not  a  matter  of  surprise  to  learn  that  a  positive  diagnosis  of 
phlegmonous  gastritis  has  never  been  attempted." 

The  purulent  collections  in  the  submucosa  are  solitary  or  numer- 
ous; the  abscesses  vary  in  size  from  that  of  a  millet  seed  to  that  of  a 
man's  fist;  they  may  perforate  either  into  the  stomach  or  the  abdom- 
inal cavity;  and  in  either  case  are  almost  surely  followed  by  death. 
According  to  Novak  (1919)  less  than  25  authentic  cases  of  circum- 
scribed phlegmonous  gastritis  (submucous  abscess)  are  on  record. 
Whether  the  disease  be  of  the  circumscribed  or  of  the  diffuse  form, 
peritonitis  without  macroscopical  perforation  of  the  gastric  wall  will  be 
the  nearly  inevitable  result;  and  unless  exploratory  operation  were  to 
be  undertaken  on  very  indefinite  symptoms,  peritonitis  will  have  de- 
veloped before  a  diagnosis  is  made. 

In  the  circumscribed  form  of  the  disease  it  is  possible  to  evacuate  the 
abscess  (Bovee,  1907)  by  operation  or  even  to  excise  the  portion  of  the 
stomach  affected  (Kaysei,  1911,  Bircher,  1912,  Novak,  1919);  but  little 
can  be  done  for  the  diffuse  phlegmonous  inflammation.  Possibly  by 
isolating  the  stomach  with  sterile  gauze  and  incising  its  walls  down  to 
the  mucosa,  or  even  by  opening  its  cavity  widely,  a  favorable  issue 
might  be  anticipated,  if  the  operation  were  done  before  general  peritoni- 
tis supervened.  Five  patients  are  said  to  have  recovered  without 
operation,  but  in  these  the  existence  of  phlegmonous  gastritis  was 
onlv  inferred. 


PHLEGMONOUS    GASTRITIS  229 

Operations   on   patients   with   phlegmonous   gastritis   have    been 
performed  by: 

1.  Leith  (Edinburgh  Hospital  Reports,   1896,  iv,  51).     Patient  pre- 

sented symptoms  of  diffuse  purulent  peritonitis.  A  median 
hypogastric  incision  seemed  to  show  that  the  inflammation  was 
more  acute  in  the  right  iliac  fossa.  A  second  incision  was 
therefore  made,  and  the  appendix  removed.  It  did  not  appear 
to  be  gravely  diseased.  The  abdomen  was  irrigated,  the  wounds 
were  closed,  but  the  patient  died  in  seven  hours.  Autopsy 
showed  that  the  peritonitis  arose  from  diffuse  phlegmonous 
gastritis,  and  that  the  inflammation  had  probably  spread  from 
the  stomach  first  to  the  right  iliac  fossa  (as  is  frequently  the 
case  with  patients  with  perforated  duodenal  ulcer),  and  had 
silbsequently  become  generalized. 

2.  Lennander  (Lengemann:  Mitth.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir., 

1902,  ix,  762).  Patient  with  diffuse  epigastric  peritonitis. 
The  stomach  seemed  to  be  the  original  seat  of  the  disease,  and  it 
was  tamponaded.  Death  in  60  hours.  Phlegmonous  gastritis 
found  at  autopsy. 

3.  Mikuhcz  (Lengemann:  Mitth.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir., 

1902,  ix,  762).  Patient  with  symptoms  of  perforated  gastric 
ulcer.  Operation  disclosed  sero-purulent  peritonitis  around 
stomach,  from  a  not  well  localized  phlegmon  of  the  gastric  wall. 
No  perforation  found.     Irrigation  and  drainage.     Recovery. 

4.  Bovee   (Trans.   Southern  Surg,  and  Gyn.  Assoc,  Dec,   1907,  in 

Jour.  Amer.  Med.  Assoc,  1908,  i,  311).  A  case  of  circumscribed 
suppurative  phlegmonous  gastritis;  recovery  after  gastrostomy. 

5.  Adams  (Lancet,  1910,  i,  292).     A  case  of  acute  primary  phlegmon- 

ous gastritis  in  a  girl  aged  13  years.  Exploratory  laparotomy. 
Death.  Peritoneal  fluid  yielded  a  pure  culture  of  the  pneumo- 
coccus. 

6.  Clarke,    Hertz,    and    Rowlands    (Guy's    Hospital  Reports,    1910, 

Ixiv,  295).  Case  due  to  swallowing  hydrochloric  acid.  A 
mucous  cast  of  the  pyloric  half  of  the  stomach  was  vomited. 
Gastro-jejunostomy.     Recovery. 

7.  Kayser     (Deutch.     med.     Woch.,     1911,     xxxvii,     631).     Partial 

gastrectomy.     Recovery. 

8.  Bircher    (Corr.    Bl.    f.    Schw.    Aerzte,    1912,    xlii,    303).     Partial 

gastrectomy  and  cholecystectomy  (duodenum  and  gall-bladder 
involved  as  well  as  stomach).     Recovery. 


230   MISCELLANEOUS  AFFECTIONS  OF  THE  STOMACH  AND  DUODENUM     ^ 

9.  Novak  (Jour.  Am.  Med.  Assoc.  191 9.  Ixxiii,  1038).  Partial 
gastrectomy  for  pyloric  tumor,  arising  from  lesser  curvature 
and  bulging,  from  a  sessile  base  6  cm.  long,  about  3  cm.  into  the 
cavity  of  the  stomach. 

Operations  for  Phlegmonoi's  G.\stritis 
Operation  Cases  Deaths 

Exploratory 4  3 

Gastrostomy i  o 

Gastro-jejunostom}'  i  o 

Partial  gastrectomy 3  o 


Volvulus  of  the  Stomach. — Volvulus  of  the  stomach  appears  to 
have  been  observed  at  least  in  35  cases.  In  ten  cases  (Bourcart, 
Hahn,  Hedlund,  Hermes,  Kocher,  Langerhans,  Mazotti,  Niosi,  Saake, 
Schiiler)  hour-glass  contraction  of  the  stomach  seems  to  have  acted 
as  a  predisposing  cause,  though  it  is  doubtful  whether  in  Saake's 
patient  a  true  volvulus  existed.  In  other  cases  no  cause  was  dem- 
onstrated, but  in  some  there  was  noted  a  marked  lengthening  of 
the  gastric  ligaments,  and  in  others  (Berg,  v.  Haberer)  a  tumor  near 
one  of  the  orifices  may  have  excited  undue  gastric  peristalsis.  The 
symptoms  are  usually  pain  in  the  epigastrium,  but  without  fever  or 
evidence  of  acute  peritonitis.  If  the  cardia  be  occluded  by  a  twist, 
there  will  be  no  vomiting,  and  introduction  of  the  stomach  tube  will 
be  difficult  or  impossible;  if  it  be  not  occluded,  vomiting  will  be  per- 
sistent; and  the  absence  of  bile  from  the  vomitus  may  be  an  indication 
that  the  pylorus  is  occluded.  The  symptoms  are  those  of  intestinal 
obstruction  and  the  physical  signs  closely  resemble  those  of  acute 
dilatation  of  the  stomach;  indeed  as  the  usual  effect  of  the  volvulus  is 
to  occlude  both  orifices,  dilatation  of  the  stomach  naturally  follows. 
As  already  remarked,  it  is  very  difficult  or  impossible  to  introduce  a 
stomach  tube;  and  this  fact  alone  shows  that  something  more  than 
mere  gastric  dilatation  exists. 

The  rotation  may  take  place  in  any  direction,  though  there  are 
three  more  or  less  typical  directions  in  which  it  usually  occurs.  These 
are:  (i)  Around  an  antero-posterior  axis,  in  which  case  the  stomach 
rotates  either  "clockwise"  or  "contra-clockwise"  as  viewed  from 
the  front;  (2)  around  a  transverse  axis  in  the  frontal  plane,  in  which 
case  the  stomach  rotates  as  an  advancing  or  as  a  retreating  wheel, 
viewed  from  the  front  of  the  body;  or  (3)  around  a  longitudinal  axis 


VOLVULUS    OF   THE    STOMACH 


231 


in  the  sagittal  plane  (an  axis  more  or  less  at  right  angles  to  the  greater 
curvature),  when  the  stomach  revolves  either  clockwise  or  contra- 
clockwise  when  viewed  from  the  head  of  the  patient.  The  most 
frequently  encountered  form  is  volvulus  around  a  transverse  axis 
in  the  direction  of  a  retreating  wheel  (21  cases  in  all).  In  most 
instances  the  transverse  colon  followed  the  stomach  upward  and  back- 
ward, being  found  between  the  stomach  below  and  the  liver  and  dia- 
phragm above.     In  Dujon's  patient  the  great  omentum,  except   at 


Liver 


Pancreas 

Trnnsvcrae 
Colon 

Duodenum 

Small 
Intestine 


Gastro-hepatic 
Omentum 


Stomaeh 

Great 
Otnentum 


Transverse 
Mesocolon 


Fig.  62. — Wiesinger's  Case  of  Volvulus  of  the  Stomach. 


the  pylorus,  and  the  gastro-splenic  omentum  were  torn  off  from  their 
gastric  attachment  by  the  volvulus.  He  found  that  he  could  not 
produce  this  form  of  volvulus  in  the  normal  cadaver,  unless  the  gastro- 
splenic  and  great  omenta  were  ruptured.  In  Borchardt's  patient  the 
transverse  colon  maintained  its  normal  position,  but  the  gastro-colic 
omentum,  which  was  very  broad,  was  stretched  to  its  utmost.  In 
most  cases  the  spleen  has  been  more  or  less  displaced;  it  may  be 
ruptured;  and  either  from  it  or  the  gastric  vessels,  profuse  hemorrhage 
into  the  peritoneal  cavity  may  occur. 


232    MISCELLANEOUS  AFFECTIONS  OF  THE  STOMACH  AND  DUODENUM 

Should  the  use  of  the  stomach  tube  prove  unavailing  in  relieving 
the  distention,  prompt  operation  is  required.  If  the  stomach  is 
very  tense,  it  should  be  evacuated  by  puncture  or  incision;  when  it 
becomes  flaccid,  the  puncture  should  be  sutured,  and  the  volvulus 
should  then  be  reduced,  if  possible.  The  surgeon  must  remember 
the  most  frequent  form  of  volvulus  (around  a  transverse  axis),  for 
it  is  often  impossible  to  determine  by  inspection  how  the  viscera 
came  to  occupy  the  positions  in  which  they  are  found.  The  trans- 
verse colon  should  be  sought:  usually  it  will  be  found  close  beneath 
the  liver  or  diaphragm,  and  the  spleen  may  be  beneath  the  ensiform 
process,  in  the  neighborhood  of  the  gall-bladder,  or  even  in  the  pelvis. 
The  posterior  wall  of  the  stomach  usually  presents,  and  has  to  be 
tapped;  then  as  the  evacuation  proceeds  the  site  of  puncture  may 
become  inaccessible,  and  Berg  was  forced  to  suture  his  first  puncture 
before  the  stomach  was  half  empty,  and  to  make  another  incision  in 
that  part  of  the  gastric  wall  which  then  became  more  accessible.  If 
reduction  cannot  be  accomplished,  the  stomach  should  be  drained,  to 
prevent  subsequent  distention,  and  in  the  hope  that  spontaneous 
reduction  may  subsequently  occur.  If  feasible  this  drainage  is  to 
be  procured  by  means  of  gastro-jejunostomy;  if  this  cannot  be  done,  a 
gastrostomy  will  suffice.  When  reduction  has  been  successfully 
accomphshed,  the  stomach  need  not  be  drained,  and  it  will  not  usually 
be  requisite  to  seek  to  prevent  a  recurrence  of  the  volvulus  by  gastro- 
pexy.  In  Berg's  first  patient  no  recurrence  was  noted,  and  he  was 
reported  as  well  more  than  ten  years  after  the  operation.  (See 
Borchardt,  loc.  infra  cit.) 

There  are  at  least  22  operations  for  gastric  volvulus  on  record. 
These  are  abstracted  below;  7  patients  died,  and  15  recovered. 

Operations  for  Volvulus  of  the  Stomach 

1.  Berg,  1895.     Evacuated  by  trocar,  untwisted.     Recovery. 

2.  Berg,    1896.     Untwisted.     Recovery. 

3.  Borchardt,    1906.     Gastrotomy;  stomach   evacuated    and   incision 

sutured;  volvulus    irreducible;  profuse    bleeding    from     spleen; 
packed.     Death. 

4.  Bourcart,    191 3.     Reduction;   gastroplasty    (hour-glass    stomach). 

Recovery. 

5.  V.  Bornsdorff,  1909.     Reduction  and  cecostom)-  (for  accompanying 

torsion  of  transverse  colon).     Recovery. 


VOLVULUS    OF    THE    STOMACH  .  233 

6.  Delangre,  1907.    Aspiration  and  reduction;  gastropexy.     Recovery. 

7.  Dujon,    1903.     Inoperable.     Death. 

8.  Gussander,    191 1    (cited  by  Hedlund,  191 1).     Reduction,  gastro- 

anastomosis;  gastrostomy.     Death. 

9.  V.  Haberer,  1912.     Pylorectomy.     Recovery. 

10.  Hermes,    1908.     Gastrostomy.     Recovery. 

11.  Jiano,    1909.     Reduction.     Death. 

12.  Kocher,  1914.     Reduction.     Recovery. 

13.  Neumann,  1906.     Reduction.     Recovery. 

14.  Niosi,    1907.     Reduction    and    gastro-jejunostomy.     Recovery. 

15.  Orth,  1913.     Reduction;  unilateral  exclusion  of  pylorus;  jejunos- 

toniy.     Recovery. 

16.  Bayer,  1904.     Reduction.     Death. 

17.  Rendl,    1904.     Puncture   and   evacuation;  reduction.     Recovery. 

18.  Schiiler  and  Walther,   1911.     Laparotomy.     Death. 

19.  Sinjuschin,  1906.     Laparotomy.     Death. 

20.  Tiirmoos,  1909.     Reduction;  gastro-jejunostomy.     Recovery. 

21.  Werner,  1911.     Reduction;  gastro-enteropexy;     Recovery. 

22.  Wiesinger,      1901.        Puncture       and       evacuation:      reduction. 

Recovery. 

Cases  of  Volvulus  of  the  Stomach 

I.  Around  anteroposterior  axis. 

(a)  Clockwise: 

I.  Kocher  (Deutsch.  Zeit.  f.  Chir.,  1914,  cxxvii,  591.) 
{b)  Contra-clockwise: 

I.  Streit  (Amer.  Jour.  Med.  Sc,  1906,  i,  967). 

II.  Around  transverse  axis  in  frontal  plane. 

(a)  As  an  advancing  wheel : 

1.  Delangre  (Revue  de  Chir.,  1907,  xxxvi,  603). 

2.  Payer  (Mitt.  a.d.  Grenzgeb.  d.  Med.  u.  Chir.,  1909,  xx, 
686). 

(b)  As  a  retreating  wheel: 

1.  Berg  (Nord.  med.  Arkiv,  Fest-Band,  Stockholm,  1895,  F. 

II,  i;  cited    by    Dujon:    Gaz.    Med.    de  Paris,   1903, 
Ixxiv,  173). 

2.  Berg  (Ibid.,  loc.  cit.). 

3.  v.  Bonsdorff  (Finska  Lakaresallsk.,  in  Jahresber.  f.  Chir. 

1909,  XV,  692). 

4.  Borchardt  (Arbeit,  a.d.  chir.  Klinik  (Bergmann),  Berlin, 
1906,  xviii,  104). 


234   MISCELLANEOUS  AFFECTIONS  OF  THE  STOMACH  AND  DUODENUM 

5.  Bourcart  (Rev.  de.  Chir.,  1913,  xlviii,  800). 

6.  Collischonn  (Beitr.  z.  Kasuistik  d.  Form  u.  Lagerungs- 

storungen    d.    Magens,    1888;  cited    by    Miihlf elder: 
Arch.  f.  Verdauungskr.,  191 1,  xvii,  53). 

7.  Collinschonn  (Ibid.,  loc.  cit.). 

8.  Dujon  (Gaz.  Med.  de  Paris,  1903,  Lxxiv,  109). 

9.  Dupre    (cited    by    Miihlf  elder:  Arch   f.   Verdauungskr., 

1 91 1,  xvii,  S3)- 

10.  Hahn    (Vortr.   i.d.   aerzt.   Vereinig.   v.   Niirnberg,    1907; 

cited   by   Miihlf  elder:  Arch.    f.    Verdauungskr.,  1911, 
xvii,  53). 

11.  Hedlund    (Miihlfelder:  Arch.    f.    Verdauungskr.,    1911, 
xvii,  53). 

12.  Hermes  (Deutsch.  Zeit.  f.  Chir.,  1908,  cxv,  310). 

13.  Jiano  (Bull.  Soc.  d.  Sc.  Med.  de  Bucharest,  1909.     16 

juin,  p.  131)- 

14.  Kerr  (Annals  of  Surgery,  191 2,  Ivi,  697). 

15.  Niosi  (Riforma  Med.,  1907.). 

16.  Pendl  (Wien.  klin.  Woch.,  1904,  xvii,  476). 

17.  Schiller    and    Walther    (Arch.    f.    Verdauungskr.,    1911, 
xvii,  82). 

18.  Sinjuschin  (Chirugia,  1906;  in  Centralbl.  f.  Chir.,  1907). 

19.  Tuffier  and  Jeanne  (Rev.  de  Gynec.  et  de  Chir.  Abdom. 

1912,  xviii,  27). 

20.  Wiesinger  (Deutsch.  med.  Woch.,  1901,  xxvii,  83). 

21.  Wilke  (Miinch.  med.  Woch.,  1907,  liv.  1012). 
III.  Around  longitudinal  axis  in  sagittal  plane. 

(a)  Clockwise  when  viewed  from  patient's  head: 

1.  Berti    (Gaz.    Med.    Ital.  Venete,  Padova  1866,  ix,  139; 

cited  by  Dujon:  Gaz.  Med.  de  Paris,  1903,  lxxiv,  109). 

2.  Oltmann    (Ein    Fall   v.    hernienartiger   Vorwolbung    d. 

Zwerchfell  m.  Achsendrehung  u.     Zerreissung  d.  Mag- 
ens.     Kiel,  1889). 

(b)  Contra-clockwise  when  viewed  from  patient's  head: 

I.  V.  Haberer  (Vcrhandl.  d.  Deutschen  Gesellsch.  f.  Chir., 
1912,  xh,  197). 

2.  Krymholz    (Chirugia,    1911,    xxix,  409;  in  Jahresber.  f. 

Chir.,  1 91 1,  xvii.  429). 

3.  Langerhans  (cited  by  Dujon:  Gaz.  Med.  de  Paris,  1903, 

lxxiv,  109). 


EVENTRATION    OF    THE   DIAPHRAGM 


23  s 


4.  Mazotti  (Rivista  Clinica  di  Bologna,  1899,  iv,  280;  cited 

by  Dujon:  Gaz.  Med.  de  Paris,  1903,  Ixxiv,  109). 

5.  Neumann    (Deutsch.  Zeit.  f.  Chir.,  1906,  Ixxxv.  136). 

6.  Orth  (Wien.  klin.  Woch.,  1913,  xxvi,  457). 

7.  Saake  (Virchow's  Arch.  f.  path.  Anat.,  1893,  cxxxiv,  181). 
IV.  Unknown  forms. 

1.  Tiirmoos  (cited  by  Miihlfelder:  Arch.  f.  Verdauungskr., 
1911,  xvii,  53). 

2.  Werner  (Ibid.). 


Fig  63. — -Eventration  of  the  Diaphragm.  Skiagram,  Anterior  View,  with  Patient 
Prone:  A,  Heart  Shadow  in  Right  Thoracic  Cavity;  B,  Left  Half  of  Diaphragm  Rising  to 
the]  Lower  Margin  of  the  Third  Rib,  C.  (H.  G.  Wood,  in  Surgery,  Gynecology  and 
Obstetrics.) 

Eventration  of  the  Diaphragm. — (Eventratio  Diaphragmatica.) 
This  rare  condition,  first  described  by  Petit  in  1790,  and  which  is  some- 
times confounded  with  diaphragmatic  hernia,  is  defined  by  Sailer  and 
Rhein  (1905)  as  "an  abnormally  high  position  of  the  left  half  of  the 
diaphragm,  with  dislocation  upward  of  the  abdominal  viscera,  par- 
ticularly the  stomach,  on  the  left  side;  hypoplasia  of  the  left  lung, 
and  displacement  of  the  heart  to  the  right."     Fischer  (1914)  referred 


236    MISCELLANEOUS  AFFECTIONS  OF  THE  STOMACH  AND  DUODENUM 

to  23  cases,  to  which  may  be  added  others  since  reported  by  Krause 
(1913),  Stein  (1914),  Upham  (1914),  and  Wood  (1916).  The  ac- 
companying illustrations  are  from  Wood's  article  (Figs.  63,  64). 

As  a  rule,  the  sjmiptoms  closely  resemble  those  of  diaphragmatic 
hernia,  which  is  more  frequent  on  the  left  than  on  the  right  side;  but 
there  is  in  eventration  of  the  diaphragm  no  history  of  sudden  onset 
nor  of  trauma;  in  the  immense  majority  of  cases  the  condition  is  con- 
genital, though  Sailer  and  Rhein  consider  it  possible  that  an  acquired 
form  may  exist.     It  has  been  suggested  that  this  may  be  due  to  a 


Fig.   64. — EvL-nira':  ■    '    •■    Duii'hrag-'       ^^'      ■  i'  •       ■■    ■     \ic\v,    with    Patient 

Prone,  Buttocks  Being  Elevated  and  Shoulders  Lowered:  A,  Heart  Shadow  in  Right 
Thoracic  Cavity;  B,  Left  Half  of  Diaphragm  in  Contact  with  Cardiac  Portion  of  Stomach. 
C.  Which  is  Well  Filled  with  Barium;  and  the  Gas  Bubbles,  D.  in  the  Pyloric  Part  of  the 
Stomach.     (Wood.) 


lesion  of  the  phrenic  nerve.  Although,  as  has  been  stated  there  is 
usually  no  history  of  a  sudden  onset,  there  may  be  exacerbations  of 
the  symptoms.  These,  if  manifested  clinically  in  any  way,  are  apt 
to  be  characterized  by  dyspnea  and  cardiac  palpitations.  The  con- 
dition is  seldom  accurately  diagnosticated  until  autopsy.  During 
life  the  most  prominent  physical  signs  are  dextrocardia  and  tympany 
in  the  lower  left  chest.     The  differential  diagnosis  from  pneumothorax 


DIAPHRAGMATIC   HERNIA  237 

and  diaphragmatic  hernia  is  important;  indeed,  it  is  only  its  resem- 
blance to  the  latter  condition  that  renders  it  of  interest  surgically. 
In  pneumothorax  some  cause  for  the  anomaly  usually  may  be  dis- 
covered, dating  its  development;  respiratory  excursion  is  absent  or 
limited,  and  the  upper  border  of  the  tympanitic  area  does  not  move 
during  respiration,  whereas  in  eventration  of  the  diaphragm  this  is 
a  constant  sign.  By  means  of  the  stomach  tube,  distention  of  the 
stomach  with  air  or  liquid  will  demonstrate  its  position,  and  a  skia- 
graphic  examination  may  show  that  the  diaphragm  retains  its  normal 
level  in  pneumothorax,  whereas  in  eventration  of  the  diaphragm  it  is 
markedly  elevated.  Diaphragmatic  hernia  usually  can  be  excluded 
by  the  history.  In  one  case  of  eventration  of  the  diaphragm  studied 
by  Widemann  (1901),  a  diagnosis  of  diaphragmatic  hernia  was  made 
a  year  later  by  Glaser.  The  patient,  48  years  of  age,  had  had  four 
attacks  of  pleurisy.  Profuse  gastric  hemorrhage  ushered  in  the  last  at- 
tack, and  the  patient  was  then  taken  to  the  hospital.  All  the  signs 
of  diaphragmatic  hernia  were  present,  but  the  first  skiagraph  made 
showed  that  the  left  side  of  the  diaphragm  was  abnormally  high,  and 
that  the  stomach  was  not  above  it  (Widemann.)  "Later  a  trans- 
verse line  below  the  clear  area  could  be  seen  moving  with  the  respira- 
tory excursion,  and  a  diagnosis  was  made  of  diaphragmatic  hernia." 
(Glaser,  quoted  by  Sailer  and  Rhein.)  As  the  hematemesis  was  re- 
peated, the  hernia  was  thought  to  be  incarcerated.  At  the  operation 
(done  by  Korte)  no  hernia  was  found.  The  patient  recovered,  but 
died  a  year  later  from  carcinoma  of  the  tongue. 

The  treatment  of  patients  with  eventration  of  the  diaphragm 
can  only  be  prophylactic  of  complications,  though  Wood  (191 6) 
suggests   that   plication   of   the   diaphragm   might  prove   of  benefit. 

Diaphragmatic  Hernia. — Diaphragmatic  hernia  is  not  veiy  rare. 
Salomoni  in  1910  was  able  to  find  records  of  about  1000  cases.  This 
form  of  hernia  may  be  classified  as  congenital  and  acquired;  but  here, 
as  in  other  hernias,  a  distinction  must  be  made  between  hernias  which 
are  present  at  birth,  and  those  which,  though  due  to  some  congenital 
defect  in  the  diaphragm,  do  not  develop  until  some  time  after  birth, 
occasionally  not  until  late  in  hfe.  Either  form  of  hernia,  moreover, 
may  happen  to  be  Intrapleural,  Subpleural,  Subdiaphragmatic,  or 
even  Intrapericardial  as  in  the  case  recorded  by  Grenier  de  Cardenal 
(1903).  Probably  the  least  usual  form  is  the  subdiaphragmatic, 
which  is  also  known  as  "true  diaphragmatic  hernia."  In  this  variety 
the  diaphragm  becomes  pouched,  and  the  muscular  fibres,  even  if  weak 
and  indistinct,  may  nevertheless  be  traced  throughout  the  walls  of 


238   MISCELLANEOUS  -DEFECTIONS  OF  THE  STOMACH  AND  DUODENUM 

the  hernial  sac.  If  the  protrusion  occurs  through  a  defect  in  the 
diaphragm,  whether  congenital  or  acquired  (by  stabwound,  gunshot 
wound,  or  traumatic  rupture  of  the  diaphragm),  the  sac  may  still  be 
Hned  by  peiitoneum;  but  this  is  very  unusual.  The  pleura  also  is 
usually  absent  over  the  hernia,  the  variety  most  frequently  encount- 
ered being  that  in  which  the  herniated  viscera  (stomach,  colon,  etc.) 
lie  free  in  the  pleural  ca\'ity — intrapleural  hernia. 

The  hernia  is  much  more  often  on  the  left  than  on  the  right  side. 
Among  282  cases  studied  by  Deitz  (1884),  in  261  (93.5  per  cent.)  the 
hernia  was  on  the  left.  The  reason  for  the  immunity  of  the  right  side 
has  always  been  said  to  be  the  presence  of  the  liver  beneath  the  dia- 
phragmatic vault,  acting  as  a  buffer,  and  materially  strengthening 
the  right  half  of  the  diaphragm.  There  are  certain  regions  of  the 
diaphragm  in  which  hernia  is  more  apt  to  occur  than  in  others;  these 
are  not,  as  might  be  expected,  the  natural  phrenic  openings,  such  as 
the  esophageal  and  caval  orifices.  Hernia  through  these  is  rare. 
There  is,  however,  a  triangular  area  found  between  the  costal  and 
sternal  attachments  of  the  diaphragm,  which  is  tilled  in  only  with 
areolar  tissue,  and  where  the  abdominal  and  thoracic  cavities  are 
not  separated  by  muscular  fibres.  This  weak  spot  is  sometimes  the 
seat  of  a  hernia;  but  more  often  the  protrusion  occurs  in  the  neigh- 
borhood of  the  left  leaflet  of  the  central  tendon  of  the  diaphragm. 
In  congenital  hernia  the  defect  is  usually  in  the  posterior  half  of  the 
diaphragm,  which  is  a  later  development  than  the  ingrowth  from  the 
ventral  surface  of  the  fetus  which  forms  the  anterior  segment  of  the 
diaphragm.  .  In  other  cases  the  hernia  is  situated  in  the  posterior 
part  of  the  diaphragm,  along  the  outer  margin  of  the  left  crus,  and 
beneath  the  internal  arcuate  ligament.  The  most  frequently  herniated 
viscera,  according  to  Deitz,  are  the  stomach,  colon,  omentum,  small 
intestine,  spleen,  liver,  duodenum,  cecum,  and  kidney — in  the  order 
named.  The  bladder,  the  rectum,  and  the  female  generative  organs 
have  never  been  found  in  a  diaphragmatic  hernia. 

Most  cases  of  diaphragmatic  hernia  are  observed  in  the  fetus, 
or  in  infants  stillborn,  or  dying  very  soon  after  birth.  In  Lacher's 
(1880)  cases,  the  age  was  recorded  in  204  instances,  and  of  these  no  less 
than  80  (40  per  cent.)  were  in  infants  less  than  one  year  old,  or  in  the 
fetus.  A  child  so  malformed  from  birth  is  very  badly  equipped  for 
the  struggle  for  existence,  and  is  prone  to  succumb  to  intercurrent 
maladies,  especially  pulmonary  affections.  Sudden  death  from  acute 
cardiac  incompetency  is  a  frequent  termination,  especially  in  adults. 
Indeed  it  has  been  said  that  diaphragmatic  hernia  should  always  be 
considered  in  deciding  the  cause  of  a  sudden  death. 


DIAPHRAGMATIC   HERNIA  239 

Males  are  supposed  to  be  more  subject  to  this  affection  than 
are  females,  especially  men  in  occupations  which  subject  them  to 
injuries  or  to  sudden  violent  strains.  Most  cases  seen  in  adults  are 
due  to  previous  injury  of  the  diaphragm  (rupture,  stab  or  gunshot 
wound). 

Subjective  sj^nptoms  are  often  wanting,  the  malformation  being 
unexpectedly  found  at  autopsy.  In  the  newborn,  cyanosis  and  dys- 
pnea are  prominent;  the  left  thorax  does  not  expand  normally;  there  is 
dextrocardia;  and  death  usually  ocurs  within  a  few  hours.  The  adult 
patient  may  have  suffered  from  mild  indigestion,  with  borborygmi,  and 
t)Tnpany  after  eating;  and  this  condition  may  have  continued  for 
years  without  material  discomfort;  at  any  time,  however,  acute  over- 
distention  of  the  herniated  stomach  may  cause  sudden  cardiac  failure, 
perhaps  death;  or  strangulation  of  the  hernia  may  arise  from  a  strain 
which  forces  a  larger  portion  of  the  abdominal  contents  through  the 
diaphragmatic  opening.  Great  thirst  is  a  symptom  on  which  stress  is 
laid  by  many  writers.  The  symptoms  due  to  stabwounds  or  gunshot 
injuries  of  the  diaphragm,  with  protrusion  of  the  stomach  or  colon,  are 
usually  overshadowed  by  those  due  to  the  injuries  to  the  abdominal 
viscera  involved. 

The  physical  signs  of  a  diaphragmatic  hernia  are  much  more  precise 
in  theory  than  in  practice.  We  know  certain  so-called  pathognomonic 
signs,  by  means  of  which  diaphragmatic  hernia  may  be  distinguished 
from  pneumothorax  and  other  conditions  which  it  resembles  more  or 
less  closely;  but  when  practical  application  is  made  of  the  tests,  it  must 
be  acknowledged  that  both  physician  and  surgeon  frequently  remain 
undecided  as  to  the  true  condition  present.  Among  the  276  cases 
collected  by  Lacher  in  1880,  only  seven  were  diagnosticated  during  life; 
and  though  our  diagnostic  acumen  has  greatly  increased,  in  regard  to 
abdominal  diseases,  during  the  last  generation,  still  it  must  be  confessed 
that  even  yet  the  diagnosis  of  diaphragmatic  hernia  may  be  difficult. 
Giffin  (191 2)  found  15  cases  in  which  the  true  condition  was  recog- 
nized during  life,  without,  or  before  operation.  We  have  references 
to  7  subsequent  case  reports  in  which  the  diagnosis  was  made  clini- 
cally or  by  the  aid  of  the  X-rays.  The  pnycical  signs  and  tests 
employed  are  fully  described  in  most  textbooks  on  the  practice  of 
medicine,  and  need  be  outlined  here  very  briefly:  The  lower  chest  on 
the  affected  side  is  tympanitic;  the  breath  sounds  are  absent  or  very 
feeble  and  distant;  vocal  fremitus  is  lost;  expansion  is  decreased;  and 
the  heart  is  dislocated  away  from  the  affected  side — that  is  to  say, 
there  is  usually  dextrocardia.     The  same  signs  exist  in  pneumothorax; 


240   MISCELLANEOUS  AFFECTIONS  OF  THE  STOMACH  AND  DUODENUM 

but  in  diaphragmatic  hernia  the  diaphragm  does  not  descend  on  deep 
inspiration,  and  causes  which  may  produce  pneumothorax  may  nearly 
always  be  absolutely  excluded,  while  a  history  of  sudden  onset  following 
severe  strain  (sometimes  childbirth)  or  a  crushing  injury,  or  occur- 
ring some  years  after  a  stabwound  or  gunshot  wound  of  the  thorax,  is 
highly  characteristic  of  diaphragmatic  hernia.  Inquiry  as  to  trauma 
some  months  or  even  years  previously  is  important,  as  in  several  cases 
such  a  history  has  revealed  the  predisposing  cause  of  the  hernia,  and 
thus  confirmed  a  diagnosis  tentatively  made  from  the  s>-mptoms  alone. 
In  such  cases  the  defect  in  the  diaphragm  may  be  congenital,  and 
the  previous  accident  may  have  been  the  first  cause  of  prolapse  of 
abdominal  viscera  through  the  opening;  but  no  symptoms  may  have 
been  noted  until  the  recent  strain,  which  produced  incarceration 
or  strangulation. 

]Moreover,  introduction  of  a  stomach  tube  and  distention  of  the 
stomach  with  air  or  liquid  (preferably  the  latter)  will  very  quickly 
change  the  physical  signs  in  the  case  of  diaphragmatic  hernia,  while 
in  pneumothorax  the  thoracic  tympany  and  other  signs  will  not  be 
affected.  The  succussion  splash,  so  characteristic  of  pneumothorax, 
may  also  be  elicited  with  great  clearness  in  many  cases  of  diaphragmatic 
hernia;  but  filling  the  stomach  with  fluid  will  have  no  effect  on  this 
phenomenon  if  due  to  pneumothorax,  while  it  will  be  speedily  abohshed, 
if  it  was  caused  by  fluid  in  an  air-containing  stomach.  Aspiration  is  to 
be  condemned  as  a  method  of  diagnosis,  the  dangers  of  consequent 
septic  pleuritis  or  peritonitis  being  very  great.  The  distinction  between 
eventration  of  the  diaphragm  and  diaphragmatic  hernia  has  been 
referred  to  at  page  235. 

A  further  aid  in  the  diagnosis  of  diaphragmatic  hernia  is  the  Roent- 
gen ray.  The  level  of  the  diaphragm  may  thus  be  detected;  and  by 
introducing  bismuth  emulsion  or  a  stomach  tube  filled  with  mercury 
into  the  gastric  cavity,  its  relation  to  the  diaphragm  may  usually  be 
determined. 

Treatment. — There  is  no  question  that  in  cases  of  diaphragmatic 
hernia  suddenly  developed,  and  of  evident  traumatic  origin,  immediate 
reduction  by  operative  means  oft'ers  the  greatest  prospect  of  recovery. 
In  such  cases,  as  in  other  irreducible  hernias  so  acquired,  the  danger  of 
strangulation  is  particularly  great,  and  the  injury  may  have  produced 
lesions  of  the  herniated  organs  (rupture,  hemorrhage,  etc.)  which  can  be 
treated  safely  only  by  surgical  means.  According  to  Lcnormant 
(1903),  among  33  cases  of  wounds  of  the  diaphragm  in  which  no  opera- 
tion was  done,  collected  in  1893  b\-  von  Frey,  there  were  29  deaths;  and 


DIAPHRAGMATIC    HERNIA  24I 

among  21  unoperated  cases  analyzed  in  iqoi  by  de  Font-ReauLx,  there 
were  16  deaths,  and  3  cases  in  which  diaphragmatic  hernia  subsequently 
developed.  On  the  other  hand,  Lenormant  himself  collected  records  of 
31  patients  with  wounds  of  the  diaphragm  which  were  operated  upon, 
and  of  these  only  7  died.  Although  this  comparison  refers  only  to  stab- 
wounds  and  gunshot  injuries,  the  conditions  in  subcutaneous  rupture 
and  in  cases  of  diaphragmatic  hernia  of  sudden  development  are  so 
similar  that  the  figures  given  are  applicable  also  to  injuries  in  which  no 
external  wound  exists.  In  cases  where  it  seems  probable  that  the 
hernia  is  of  long  duration,  and  due  to  a  congenital  defect  in  the  dia- 
phragm, delay  in  resorting  to  operation  is  justifiable;  but  if  the  signs  of 
incarceration  or  obstruction  arise,  no  further  time  should  be  lost — the 
hernia  must  be  reduced  by  operative  means  before  strangulation  has 
made  reduction  useless  by  producing  edema,  sloughing,  and  gangrene 
of  the  herniated  viscers. 

According  to  John  Wood  (1888)  it  was  Guthrie  who  first  proposed 
''to  make  an  opening  in  the  abdominal  cavity,  and  to  introduce  the 
hand  in  order  to  withdraw  the  bowel  from  the  hernial  opening." 
Permann  and  Postempski  proposed  in  1 889,  independently  of  each  other, 
the  operation  of  thoracotomy,  Permann  advocating  it  for  ordinary  cases 
of  diaphragmatic  hernia,  while  Postempski  urged  it,  and  successfully 
employed  it  in  several  cases,  for  wounds  of  the  diaphragm.  The  first 
operation  (laparotomy)  in  a  non-traumatic  case  appears  to  have  been 
carried  out  in  1879  by  Bardenheuer  (the  hernia  not  being  discovered 
until  postmortem  examination),  while  Postempski  in  1889  did  the  first 
operation  (thoracotomy)  for  stab-wound.  Naumann,  in  1888.  appears 
to  have  been  the  first  to  find  the  hernia  at  operation  (laparotomy) ;  he 
was,  however,  unable  to  reduce  it.  Surgeons  are  divided  as  to  the 
route  by  which  the  rent  in  the  diaphragm  should  be  approached,  some 
preferring  laparotomy,  but  most  are  in  favor  of  thoracotomy.  In  1910, 
Salomoni  collected  51  operations,  with  39  deaths  (76.2  per  cent.): 
II  thoracotomies,  with  4  deaths  (36.3  per  cent.)  and  39  laparotomies 
with  35  deaths  (89.7  per  cent.).  In  most  if  not  all  of  the  early  cases, 
operation  was  done  only  when  strangulation  occurred,  and  in  most  of 
these  the  only  pre-operative  diagnosis  was  intestinal  obstruction,  and 
in  many  the  cause  of  the  obstruction  (diaphragmatic  hernia)  was 
not  found  at  operation  (laparotomy). 

In  cases  where  strangulation  is  not  present,  and  where  the  true 
condition  is  recognized  before  operation,  or  is  found  accidentally 
during  operation  for  some  other  condition,  the  prospects  of  recovery 

16 


242    MISCELLANEOUS  AFFECTIONS  OF  THE  STOMACH  AND  DUODENUM 

are  excellent.  Unless  the  patient's  condition  forbids  it,  we  believe 
that  in  such  cases  reduction  of  the  hernia  and  repair  of  the  diaphrag- 
matic opening  should  be  attempted.  Among  ii  recent  cases  of  this 
kind  to  which  we  have  reference  (Beckmann,  1909  (3  cases);  Bythell 
(1915);  Carson  (1912);  Cranwell  (1908);  Giffin  (1912);  Harris  and 
Greene  (1912);  McGuire  (1914),  2  cases;  Scudder  (1912)),  there 
were  no  deaths  but  in  several  of  these  cases  no  attempts  were  made 
to  repair  the  diaphragm.  Four  recent  operations  for  strangulated 
diaphragmatic  hernia  (Bamberger,  1910;  Caflfee,  1911;  Litler- Jones, 
1909;  Thompson,  1909)  are  on  record,  with  only  2  recoveries. 

In  favor  of  thoracotomy  is  the  fact  that  the  lung  is  already  col- 
lapsed and  the  heart  displaced,  so  that  even  wide  opening  of  the  pleural 
cavity  could  not  materially  increase  the  danger  on  that  score;  the 
greater  accessibility  of  the  diaphragmatic  opening  also  would  make 
us  prefer  thoracotomy.     More  important,  however,   than  either  of 
these  factors,  is  the  existence  of  negative  pressure  in  the  unopened 
pleura;  the  herniated  viscera  are  thus  held  in  the  pleural  cavity  by 
suction,    and   reduction   by   traction   from   within    the  abdomen  is 
difEcult,  if  not  impossible.     Indeed,  the  only  reason  we  can  see  for 
preferring  the  abdominal  route  would  be  the  possibility  of  injury  to 
some  abdominal  organs  which  could  not  be  repaired  from  above.     A 
study  of  the  cases,  however,  in  which  operation  has  been  done  for 
diaphragmatic  hernia,  has  convinced  us  that  in  the  immense  majority 
0]    cases    thoracotomy    should    he    the    operation    employed.     Unless 
local  anesthesia  is  employed,  the  anesthetic  (ether)  should  be  adminis- 
tered by  intratracheal  insufHation.     The  technique  consists  in  open- 
ing the  pleural  cavity,  reducing  the  hernia,  repairing  the  defect  in  the 
diaphragm,    and  closing  the  primary  incision.     In  many  cases  an 
intercostal  incision,  preferably  in   the   eighth  interspace,   will  give 
sufficient  exposure  if  the  ribs  are  forcibly  drawn  asunder  by  strong 
retractors.     The  flap  operations  of  Postempski,  Rydygier,  and  others 
are  not  necessary,  and  should  therefore  not  be  employed.     If  the 
simple  intercostal  incision  does  not  give  sufficient  exposure,  one  or 
two  ribs — those  bordering  on  the  primary  incision- — may  be  resected 
for  a  distance  of  four  or  five  inches.     More  room  than  is  thus  obtained 
is  seldom  requisite.     Should  temporary  resection  of  the  chest  wall 
be  employed,  Rydygier's  operation  is  to  be  preferred  to  that  of  Post- 
empski.    Rydygier  made  an  intercostal  incision,  enlarging  the  existing 
stabwound,  and  joined  this  at  its  posterior  extremity  by  an  incision 
made  downward  from  it,  practically  at  right  angles  to  the  ribs.     The 
ribs  are  then  divided  in  the  line  of  the  second  incsion,  and  the  osteo- 


DIAPHRAGMATIC   HERNIA  243 

plastic  flap  thus  formed  is  turned  downward  and  forward,  the  elastic 
costal  cartilages,  which  are  not  divided,  acting  as  a  hinge.  In  Post- 
empski's  operation  the  ribs  are  divided  front  and  back,  and  the  flap 
thus  made  is  turned  directly  downward.  InCranwell's  operation  (1908) 
a  flap  similar  to  Postempski's  was  employed,  but  with  the  base  above. 
In  some  instances  the  flap  formed  by  Postempski's  method  has 
sloughed.  The  use  of  hot  moist  compresses  of  silk  or  of  handker- 
chief gauze,  to  isolate  the  operative  field  from  the  upper  portion  of  the 
pleural  cavity  and  the  lung,  is  of  great  assistance,  and  lessens  any 
symptoms  which  may  arise  from  the  operative  pneumothorax.  In 
cases  of  stabwound,  or  of  traumatic  hernia,  great  care  should  be 
taken  to  repair  any  injury  of  the  stomach,  colon,  or  other  structures 
found  in  the  pleural  cavity.  As  such  injuries  are  in  the  upper  or 
posterior  walls  of  the  stomach,  they  are  readily  accessible  by  the 
transpleural  route,  but  are  very  difficult  of  access  or  totally  inacces- 
sible by  laparotomy.  After  all  ruptures  or  perforations  are  repaired,  the 
herniated  organs  are  to  be  reduced,  and  the  breach  in  the  dia- 
phragm sutured.  If  this  be  very  large,  the  omentum  may  be  attached 
to  its  margins,  by  sutures;  but  usually  it  has  been  possible  to  close  it 
without  the  use  of  omentum.  It  is  better  not  to  drain  the  pleural 
cavity;  even  if,  in  a  few  cases,  immediate  closure  of  the  thoracic  wound 
without  drainage  results  in  subcutaneous  emphysema,  or  in  the  devel- 
opment of  hemothorax  or  empyema.  These  latter  complications 
may  be  remedied  by  a  secondary  thoracotomy;  if  primary  drainage  is 
instituted  in  every  case,  the  total  number  of  cases  of  pyothorax  will 
be  much  increased.  In  Riegner's  patient  with  stab  wound  of  the 
diaphragm,  the  abdomen  was  opened  after  repairing  the  herniated 
organs  and  the  diaphragm  by  thoracotomy;  but  as  no  abdominal 
lesion  was  found,  the  laparotomy  wound  was  immediately  closed. 
While  it  is  certainly  safer  to  explore  the  abdomen  if  there  is  a  prob- 
ability of  further  lesions,  in  most  cases  such  good  exposure  has  been 
obtained  by  means  of  thoracotomy  that  no  secondary  laparotomy  has 
been  employed. 

If  no  diagnosis  other  than  intestinal  obstruction  has  been  made, 
laparotomy  will  be  the  operation  employed;  but  if  reduction  of  the 
hernia  prove  difficult  from  below,  the  surgeon  should  not  hesitate 
to  create  a  pneumothorax  by  means  of  thoracotomy,  as  has  been 
done  by  Dennis  (1905)  and  others,  to  reUeve  the  negative  pressure 
within  the  pleural  cavity. 


CHAPTER  XI 
CARCINOMA  OF  THE  STOMACH 

Carcinoma  of  the  stomach  is  a  disease  of  frequent  occurrence.  From 
25  to  40  per  cent,  of  all  cancers  in  the  body  are  primary  in  the  stomach. 
Statistics  show  that  over  13  per  cent,  of  deaths  due  to  diseases  of  the 
digestive  organs  are  caused  by  carcinoma  of  the  stomach.  In  America 
as  well  as  in  other  ci\'ilized  countries  the  frequency  of  carcinoma  is 
increasing.  According  to  Hoffman  (1914)  the  number  dying  from 
cancer  is  about  25  per  cent,  greater  than  ten  years  ago.  The  United 
States  Census  report  for  1900  recorded  9000  deaths  from  cancer 
during  that  year;  31  per  cent,  of  fatal  cancers  were  in  the  stomach; 
probably  (as  we  shall  see  later)  man}'  cancers  of  the  liver  and  the  abdo- 
men were  primarily  gastric;  and  many  cases  recorded  as  gastritis  and 
allied   diseases  were   really  carcinomatous  in  nature   (Dowd,    1906). 

Etiology  and  Pathology. —  The  cause  of  cancer  is  unknown.  Direct 
curative  treatment  is  therefore  at  present  impossible.  The  only  way  to 
keep  the  patient  so  afflicted  from  being  killed  by  the  disease  is  to  remove 
it  in  toto. 

In  studying  carcinoma  of  the  stomach  it  is  especially  the  predis- 
posing causes  of  its  existence  that  must  be  considered,  because  little  is 
known  of  the  exciting  causes.  It  is  shown  under  the  discussion  of 
Treatment  that  surgery  is  dealing  effectively  with  some  of  these 
predisposing  causes. 

Race. — Carcinoma,  whether  of  the  stomach  or  other  region  of  the 
body  is  peculiarly  an  affection  of  the  Caucasian  race.  Friedenwald 
(1914),  practising  in  Baltimore,  Md.,  which  has  a  large  colored  popula- 
tion, observed  carcinoma  of  the  stomach  only  in  52  negroes  among  a 
total  of  1000  patients  with  the  disease,  or  in  5.2  per  cent.  The  yellow 
races  seem  more  vulnerable  than  the  black,  while  the  white  races 
are  most  liable  to  its  presence. 

Sex  has  very  little  influence  on  the  occurrence  of  the  disease. 
Among  1303  cases.  Fox  observed  680  men  and  625  women;  in  2214 
cases  studied  by  Welch,  1233  were  males  and  981  females.  Fenwick 
(1902),  after  quoting  these  figures,  gives  the  results  of  his  own  researches: 
among  3679  post  mortem  examinations  of  gastric  cancer,  2162  were 
males,  and  1517  females,  a  proportion  of  rather  less  than  6  to  4.     But, 

-'44 


•    PREDISPOSING    CAUSES  245 

as  Fenwick  points  out,  it  is  to  be  remembered  that  men  form  a  larger 
proportion  of  hospital  patients  and  of  the  subjects  of  post  mortem 
examination  than  do  women,  so  that  even  these  figures  may  exaggerate 
the  relative  frequency  of  gastric  carcinoma  in  men.  But  in  the  statis- 
tics of  Smithies  (1916)  recently  published,  among  921  patients,  693 
were  male,  and  only  228  female,  a  proportion  of  morp  than  3  to  i. 

Age. — About  80  per  cent,  of  all  cases  of  gastric  carcinoma  occur 
in  patients  between  the  ages  of  49  and  70  years.  It  is  rare  below  the  age 
of  20  and  over  that  of  80  years.  Bernouilli  (1907)  reported  three  cases 
that  came  under  his  own  observation  in  which  there  was  carcinoma  of  the 
stomach  or  rectum  in  patients  aged  15,  17,  and  18  years  respectively.  He 
also  collected  50  cases  from  the  literature  in  which  carcinoma  had  been 
found  in  the  young,  the  stomach  being  the  site  of  disease  in  13.  In  one 
instance  the  cancer  of  the  stomach  was  evidently  congenital. 

Trauma  may  determine  the  occurrence  of  carcinoma  in  the  stomach. 
Ropke  (1905)  found  trauma  a  direct  cause  of  gastric  carcinoma  in  2 
out  of  79  cases  observed;  Friedenwald  (1914)  obtained  a  definite 
history  of  trauma  in  19  out  of  1000  patients,  nearly  2  per  cent.;  while 
Smithies  (1916)  reports  it  as  a  cause  in  2.6  per  cent,  of  his  921  cases. 
Lacerations  of  the  mucosa,  from  acute  distention  of  the  stomach, 
have  been  suggested  by  Strassmann  (1907)  and  others  as  the  starting 
point  of  gastric  ulcers  and  cancers.     (See  p.  298.) 

Simple  Gastric  Ulcer. — There  is  no  factor  which  of  late  years  has 
attracted  so  much  attention  as  a  predisposing  cause  of  gastric  cancer 
as  has  simple  gastric  ulcer.  Long  recognized  under  the  terms  "chronic 
gastritis,"  "dyspepsia,"  "indigestion,"  etc. ,  a  more  intimate  knowledge  of 
these  cases  has  shown  that  in  most  patients  these  digestive  disturbances 
were  due  to  the  presence  of  an  ulcer  or  its  sequels  (cicatrices,  stenosis 
of  the  pylorus,  etc.).  And  the  evidence  that  carcinoma  is  frequently 
an  end  result  of  such  lesion  has  been  accumulating  for  more  than  a 
decade.  Thus  Mumford  and  Stone  (1905)  traced  60  patients  who  had 
been  treated  at  the  Massachusetts  General  Hospital  for  "chronic  indi- 
gestion," and  who  subsequently  died.  Of  these  no  less  than  half  died 
of  gastric  carcinoma.  These  writers  further  made  a  study  of  50  patients 
with  gastric  carcinoma  and  learned  that  in  no  less  than  41  of  the  50 
patients  there  was  "a  history  either  of  ulcer  or  of  long-continued 
digestive  disturbance,  of  which  the  exact  nature  could  not  be  ascer- 
tained." W.  J.  Mayo  in  1905  found  a  history  of  ulcer  or  other  gastric 
disease  in  36  per  cent,  of  his  patients  with  cancer  of  the  stomach,  and 
detected  clear  evidence  of  cancer  having  developed  on  ulcer  in  30  per 
cent,  of  the  last  forty  partial  gastrectomies  performed;  in   1907  he 


246 


CARCINOMA    OF    THE    STOMACH 


reported  that  the  dinical  history  of  69  patients  with  gastric  cancer, 
and  pathological  examination  of  the  specimens  removed  from  them  by 
gastrectomy,  during  1905  and  1906,  made  it  clear  that  in  54  per  cent, 
the  cancer  had  its  origin  in  an  ulcer.  In  1914  ^lacCarty  and  Broders 
reported,  from  the  IMayo  Clinic,  that  472,  or  69  per  cent.,  of  684  speci- 
mens of  gastric  lesions,  excised  or  resected  at  operation,  presented 
characteristics  of  simple  ulcer  plus  carcinoma ;  in  3  per  cent,  more  the 
existence  of  carcinoma  was  doubtful;  while  only  in  191  (28  per  cent, 
of  the  total)  was  there  certainly  no  carcinoma.     Of  399  operation  speci- 


FlG.  65. — Microphotograph  iLow  Power)  showing  L\i;  _i:i_:.  a  Beginning  in  Edge  of  Gas- 
tric Ulcer.     See  Fig.  66.     From  a  Patient  in  the  Lankenau  Hospital.    (Dt.  Reiman.), 


mens  of  gastric  carcinoma  studied  by  Wilson  and  ^McDowell  (Mayo 
Clinic,  1914): 

53.6  per  cent  showed  unmistakable  evidence  of  pre\T[ous  ulcer, 
4.8  per  cent,  showed  doubtful  e\idence  of  previous  ulcer,  and 
42.6  per  cent,  showed  no  evidence  of  previous  ulcer. 

Kocher  (1912)  found  in  his  series  only  8  to  9  per  cent,  with  microscopical 
evidence  of  preceding  ulcer,  but  in  72  per  cent,  of  his  patients  with 
cancer  of  the  stomach  there  was  a  history  of  ulcer;  and  from  13  to  43 
per  cent,  of  lesions  excised  under  the  diagnosis  of  ulcer  proved  really 
to  be  carcinomatous.  Our  own  statistics  do  not  give  so  high  a  percen- 
tage: of  143  patients  operated  on  at  the  Lankenau  Hospital  for  gastric 
carcinoma  (1909  to  1920),  44,  or  30.7  per  cent.,  gave  a  previous  history 


ULCER   AND    CANCER 


247 


characteristic  of  ulcer;  and  among  the  last  100  specimens  of  gastric 
carcinoma  removed  at  operation,  which  have  been  carefully  studied  by 
Reiman  (1920)  38  gave  evidence  of  having  developed  on  an  ulcer  base. 
(Figs.  65  and  66.)  Physicians  claim  a  much  lower  incidence  of  previous 
ulcer  history  than  most  of  the  figures  quoted  above.  Thus  Friedenwald, 
among  1000  cases  of  carcinoma  of  the  stomach,  noted  a  history  of  previous 
digestive  disturbance  only  in  23  per  cent.,  and  only  7.3  per  cent,  gave 
a  definite  history  of  ulcer.  Lockwood  (1913)  notes  that  of  174  cases  of 
cancer  of  the  stomach  in  which  the  previous  history  was  complete,  148 


f*t. 


mm-r'; 


Fig.  66. — Microphotograph  (High  Power),  showing  Early  Carcinoma  (see  Pig.  65). 


(86  per  cent.)  gave  no  history  of  previous  digestive  trouble;  13  (7  per 
cent.)  had  an  indefinite  history  of  indigestion,  not  suggesting  ulcer,  and 
only  13  in  all  (7  per  cent.)  gave  a  history  that  indicated  previous 
ulceration.  Smithies  reports  the  following  figures  in  a  study  of  921 
cases  of  carcinoma  of  the  stomach: 

Ulcer,  with  microscopical  evidence  of  carcinoma,  7.8  per  cent.; 
average  duration  of  symptoms  13.7  years. 

Clearly  cancer  when  first  seen,  with  a  history  of  ulcer,  47.3  per  cent. ; 
average  duration  of  ulcer  symptoms  10.5  years,  succeeded  by  average 
period  of  malignant  symptoms  for  6.3  months. 


248  CARCINOMA    OF    THE    STOMACH 

No  previous  stomach  history,  31  per  cent.;  average  duration  7 
months. 

Previous  vague  stomach  history,  9  per  cent.;  average  duration  9 
years,  with  an  average  period  of  mahgnant  symptoms  for  6.2  mos. 

Few  cHnical  signs  of  stomach  disease,  2  per  cent. 

Carcinoma  of  stomach  secondary  to  carcinoma  elsewhere,  1.7  per 
cent. 

Almost  alone  among  modern  surgeons  Paterson  (19 14)  argues 
against  the  frequency  of  gastric  ulcer  as  a  previous  lesion  to  gastric 
carcinoma.  Kiittner  (1914)  also  appears  to  hold  this  view,  as  the  result 
of  his  study  of  material  from  iioo  operations;  but  he  claims  that  a 
large  number  of  callous  ulcers  of  the  stomach  are  mahgnant  from  the 
very  beginning.  If  Paterson's  arguments  are  carefully  analyzed,  it  will 
be  found  that  he  is  reduced  to  the  same  conclusion.  And  it  is  interest- 
ing to  note  a  statement  by  Judd  of  the  Mayo  Clinic  (191 9)  that  it  is 
now  generally  recognized  that  most  carcinomata  of  the  stomach  have 
not  originated  in  simple  ulcers  but  have  been  malignant  from  their 
beginning. 

It  should  be  noted  also  that  other  pathologists  than  those  associated 
with  the  Mayo  Chnic  have  not  accepted  as  evidence  of  carcinomatous 
transformation  in  ulcers  changes  which  Wilson,  MacCarty  and  their 
colleagues  have  exhibited  as  such. 

Konjetzni  (1913)  collected  statistics  on  this  subject  from  various 
clinics,  comprising  a  total  of  2337  cases  of  carcinoma  of  the  stomach: 
the  number  which  were  thought,  after  histological  study,  to  have 
originated  as  simple  ulcers  varied  from  i  to  22  per  cent.;  so  that  he 
regarded  Wilson  and  MacCarty 's  figures  (71  per  cent.)  as  altogether 
exceptional. 

A  sensible  conclusion,  it  seems  to  us,  is  that  in  from  one  third  to  one 
half  of  all  gastric  cancers  the  history  is  that  of  ulcer,  and  that  early 
diagnosis  and  treatment  of  gastric  carcinoma  consists  in  diagnosis  and 
operation  on  cases  of  gastric  ulcer. 

The  histological  changes  by  which  simple  ulcer  becomes  converted 
into  carcinoma  have  been  particularly  investigated  by  the  French 
pathologists,  and  in  this  country  especially  by  MacCarty  and  Wilson, 
of  the  Mayo  Clinic.  Although,  as  already  indicated,  their  theories 
are  not  unreservedly  accepted  by  other  writers,  they  seem  to  merit 
a  short  description  in  this  place,  especially  as,  when  considered  in  this 
light,  these  changes  may  be  regarded  as  in  the  nature  of  predisposing 
causes.  Hayem  described,  as  long  ago  as  1895,  certain  adenomatous 
changes  in  the  pyloric  region,  which  he  characterized  as  Brunnerian  in 


CLINICAL    PATHOLOGY 


249 


type — that  is  to  say,  resembling  the  glands  of  Brunner,  which  are  found 
in  the  duodenum,  and  which  are  distinguished  from  the  gastric  glands 
by  their  situation  within  the  submucosa,  the  gastric  glands,  as  is  well 
known,  never  extending  below  the  muscularis  mucosa;.  These  adeno- 
mata of  Brunnerian  type,  occurring  in  the  pyloric  region  of  the  stomach, 
are  clearly  neoplastic  in  character,  and  were  regarded  by  Hayem  as  an 
early  stage  of  carcinomatous  transformation.  Menetrier  in  igoo 
elaborated  earlier  studies  by  himself  along  the  same  line.  He  summed 
up  his  theory  of  carcinomatous  transformation  in  this  way:  First 
stage^ — this  is  purely  inflammatory;  there  is  a  chronic  gastritis  and  the 
cells  hning  the  glands  lose  their  special  and  distinctive  features  (the 
histological  picture  is  simphfied);  and  the  "acid"  cells  disappear. 
Second  stage — adenomatous  in  character;  the  proliferating  glands,  de- 
prived of  their  characteristic  elements,  become  more  contorted  and 
convoluted;  the  cells  increase  in  number;  cysts  form  as  the  result  of 
obstruction  of  the  gland  ducts  by  proliferation  of  their  lining  cells. 
Third  stage — epitheliomatous  in  character;  the  cells  break  through  the 
muscularis  mucosae  and  hnall}^  are  found  lying  free  among  the  connec- 
tive tissues  of  the  gastric  walls.  It  is  the  great  frequency  with  which 
MacCarty  found  similar  changes  in  the  periphery  of  gastric  ulcers, 
rather  than  anything  new  histologically,  that  renders  his  investigations 
of  interest.  It  must  be  acknowledged  that  the  statement  of  Ewing,  to 
the  effect  that  a  histological  picture  does  not  have  to  be  either  malignant 
or  non-malignant,  but  that  it  may  be  neither  the  one  nor  the  other, 
represents  a  very  convenient  state  of  mind  for  pathologists  to  maintain. 
Clinical  Pathology.  Situation. — The  following  table  shows  the  lo- 
cation of  the  growth  in  1850  cases  collected  by  Fenwick,  as  well  as  in 
854  cases  studied  personally  by  Smithies: 


t~i 

dj 

S 

Distribution  of  carcino- 

3 

0 

3 

M 

0      l-i 

£  s 

mata  in  the  stomach 

3 

0 

a. 

is 

■-3 

6 

01     c3 

0  " 

3 

a 
3 

^     60 

-3    2 

Fenwick  (per  cent.). . .  . 

S8 

"■5 

9.8 

S-o 

2.8 

2.2 

1-5 

6 

2.9 

Smithies  (per  cent.) 

42 

24-7 

3-5 

9-3 

2-3 

2-3 

0.9 

12 

2.9 

Fenwick  concluded  from  his  figures,  "that  in  79.4  per  cent.,  or  in 
about  four-fifths  of  all  cases,  carcinoma  commences  in  the  compara- 
tively small  strip  of  tissue  which  extends  from  one  orifice  to  the  other 
along  the  upper  margin  of  the  stomach,  and  that  its  percentage  rapidly 


250  CARCINOMA    OF    THE    STOML^CH 

diminishes  the  further  we  proceed  from  the  pyloric  valve."  The  nearly 
identical  distribution  of  cases  of  callous  ulcer  is  a  further  indication  of 
the  probable  relation  between  the  two  affections. 

Histological  Structxire. — ^Microscopically,  three  tj-pes  of  gastric 
cancer  are  recognized:  (i)  A  tumor  composed  of  spheroidal  cells  Hke 
those  normally  lining  the  gastric  tubules  (spheroidal  celled  carcinoma) ; 
(2)  a  tumor  composed  of  more  or  less  columnar  or  cyhndrical  cells, 
similar  to  those  normally  hning  the  pyloric  glands  (cyhndrical  celled  or 
adeno-carcinoma) ;  (3)  a  tumor  whose  chief  characteristic  is  m>'xoma- 


^ 

1'    M 

^^H^^B^  flr                     "'^Bm^rJ^ 

k 

Rnralk^ 

%ti 

^^^            ''tJr^          'sl^eaf^ 

Fig.  67. — Carcinoma  of  Stomach;  Specimen  Removed  by  Partial  Gastrectomy. 
Man  43  Years  of  Age,  Gastric  Symptoms  for  Two  Months  Only;  Loss  of  Weight  52  lbs. 
Tumor  Doubtfully  Palpable.  In  Good  Health,  Free  from  S\Tnptoms,  and  has  Gained 
40  lbs.  in  Weight,  16  Months  after  Operation.  See  Fig.  68.  From]  a  Patient  under 
the  Junior  Author's  Care  in  the  Episcopal  Hospital. 

tous  degeneration  of  epithehal  cells  and  stroma  (colloid  carcinoma), 
which  may  be  the  result  of  changes  either  in  the  spheroidal  celled  or  the 
cyhndrical  celled  carcinoma.  Finally  these  tumors  are  described  as 
scirrhus  or  medullary  (encephaloid)  according  as  they  are  rich  or  not  in 
fibrous  tissue  as  compared  with  the  cellular  elements  present.  It  is 
perhaps  well,  from  a  cUnical  point  of  view,  to  bear  in  mind  also  the 
term  (4)  ulcus  carcinomatosum,  or  carcinomatous  ulcer  (Fig.  68), 
which  indicates  that  the  main  feature  of  the  growth  is  an  ulcer,  whether 
the  ulcer  was  originally  benign  or  was  malignant  ah  initio,  or  was  the 
result  of  sloughing  of  a  scirrhus  or  a  medullarv  carcinoma. 


METASTASIS 


251 


There  does  not  appear  to  be  sufficient  material  for  it  to  be  decided 
which  variety  of  carcinoma  occurs  most  frequently.  As  a  matter  of 
fact,  the  spheroidal  and  the  cylindrical  cell  types  both  may  be  present 
in  the  same  tumor,  or  colloid  changes  may  completely  obscure  the  field. 
Brinton's  figures  (1857)  indicated  that  72  per  cent,  of  gastric  carcino- 
mata  were  of  the  scirrhous  variety;  but  more  recent  statistics  compiled 
according  to  Brinton's  method  tend  to  show  that  the  medullary  forms 


Pig.  68. — Carcinoma  of  Stomach:  Specimen  Shown  in  Pig.  67  has  been  Opened  Along 
the  Lesser  Curvature;  Exposing  Large  Callous  Ulcerated  Cancer  Involving  Nearly  Entire 
Circumference  of  Stomach.  Prom  a  Patient  tinder  the  Care  of  the  Junior  Author  in  the 
Episcopal  Hospital. 


predominate.  Fenwick  studied  115  cases  of  gastric  carcinoma  micro- 
scopically, and  reported  63.5  per  cent,  as  spheroidal  celled,  28.6  per 
cent,  as  cylindrical  celled,  and  7.8  per  cent,  as  exhibiting  signs  of  colloid 
degeneration. 

Metastasis  occurs  early  in  carcinoma  of  the  stomach,  but  for  a 
reasonable  time  this  metastasis  is  confined  to  the  immediately  adjacent 
lymph  nodes.  According  to  Mumford,  in  from  4  to  10  per  cent,  of 
those  patients  with  thp  perigastric  lymph  nodes  palpably  enlarged,  no 


252  CARCINOMA    OF    THE    STOMACH 

carcinomatous  invasion  of  these  lymph  nodes  exists.  The  lymphatics 
of  the  stomach  have  already  been  discussed  (p.  13).  Our  knowledge 
of  these  lymphatic  areas  is  due  almost  entirely  to  the  classical  investiga- 
tions of  Cuneo  (1903);  and  Hartmann  (1904)  was  the  first  to  make 
practical  applications  of  his  teachings  in  performing  excision  for  gastric 
cancer.  ]\lore  recent  investigations  have  invalidated  the  conclusions 
of  Cuneo  in  some  anatomical  details,  but  the  practical  lessons  to  be 
drawn  from  Cuneo's  researches  are  in  no  way  affected.  The  chief  of 
these  lessons  is  that  carcinoma,  beginning,  as  it  usually  does,  along  the 
lesser  curvature  close  to  the  i)}lorus,  invades  first  the  lymph  nodes 


Fig.  69. — Carcinoma  of  Stomach:  Specimen  Removed  by  Subtotal  Gastrectomy,  see  Pig. 
70.      From  a  Patient  under  the  Senior  Author's  Care  in  the  Lankenau  Hospital. 

lying  along  the  lesser  curvature;  and  that  this  chain  of  lymph  nodes  is 
very  quickly  invaded  even  up  to  the  coronary  group  of  nodes  surround- 
ing the  coronary  artery  close  to  the  cardiac  orifice.  From  this  fact  it  is 
evident  that  radical  operations  for  gastric  cancer  must  remove  prac- 
tically the  entire  lesser  curvature  of  the  stomach.  Moreover,  as  soon 
as  the  carcinoma  is  at  all  extensive,  it  is  found  that  the  lymph  nodes 
in  the  gastro-coHc  omentum,  for  a  variable  distance  away  from  the 
pylorus,  are  involved.  Hence  Hartmann  s  line  for  gastrectomy  was 
made  to  pass  from  the  coronary  artery  to  a  point  nearly  directly  below 
it,  on  the  greater  curvature  of  the  stomach  (Fig.  iii).  A  third  point  of 
the  greatest  importance  is  that  whereas  the  carcinomatous  invasion 


METASTASIS 


253 


extends  rapidly  and  for  an  indefinite  distance  away  from  the  pyloric 
region  of  the  stomach,  it  invades  the  duodenum  only  rarely.  The 
removal  of  the  first  2  cm.  of  the  duodenum  will  nearly  invariably  enable 
the  surgeon  to  get  safely  beyond  the  limits  of  the  malignant  growth. 
It  is  a  well-recognized  fact  that  the  palpable  induration  of  the  gastric 
cancer  stops  with  the  area  of  mucosa  affected,  but  that  in  the  sub- 
mucosa  the  invasion  will  have  advanced  considerably  further:  hence 
the  necessity  of  cutting  wide  of  the  indurated  margins  of  the  carcinoma. 
From  Borrmann's  studies  of  resected  stomachs  from  the  clinique  of 


•*!>*'    ""tV. 


Fig.  70. — Carcinoma  o£  Stomach:  Looking  Toward  the  Pylorus.  Specimen  Shown  in 
Fig.  69  has  been  Opened  Part  Way  Along  the  Greater  Curvature  from  the  Cardiac  End  of 
the  Specimen.      (Lankenau  Hospital.) 

Mikulicz  it  is  evident  that  these  incisions  must  be  made  from  5  to  8  cm. 
(two  to  three  and  a  half  inches)  away  from  the  macroscopical  tumor  on 
the  cardiac  side  of  the  growth,  and  from  1.5  to  2  cm.  (one-half  to  three- 
fourths  of  an  inch)  from  it  on  the  intestinal  side. 

While  Cuneo  found  that  the  presence  of  lymph  nodes  beneath 
the  pylorus  was  very  unusual,  Jamieson  and  Dobson  (1907)  found 
them  quite  frequently  present,  thus  confirming  the  observations  of 
Lengemann,  who  noted  their  presence  in  60  per  cent,  of  the  stomachs 
examined.  But  Cuneo 's  conclusion  that  the  removal  of  these  nodes 
is  rarely  necessary,  is  paralleled  by  Jamieson 's  and  Dobson 's  asser- 


2  54  CARCINOMA    OF    THE    STOM.ACH 

tion  that  their  removal  would  be  extremely  difficult,  if  not  impos- 
sible, and  that  it  probably  is  very  rarely  accomplished.  And,  while 
Cuneo  thought  that  the  pylorus  and  the  whole  of  the  lesser  curvature 
drained  into  the  lower  coronary  group  of  nodes  as  they  are  named  by 
Jamieson  and  Dobson,  these  writers  found  that  in  not  a  few  instances 
lymph  channels  may  be  traced  which  pass  directly  past  these  nodes 
and  emptj'  into  the  right  supra-pancreatic  nodes  lying  along  the 
trunk  of  the  hepatic  artery.  The  disheartening  conclusion  is  reached 
by  Jamieson  and  Dobson.  as  a  result  of  their  studies,  that  "  except  as 
a  mere  matter  of  chance  no  operation  for  gastric  carcinoma  can  be 
a  radical  one  when  once  maUgnant  emboU  have  commenced  to  reach 
the  lymphatic  glands.  The  only  reason,"  they  add,  "  for  removing 
as  many  of  the  diseased  glands  as  possible,  is  the  hope  that  once  the 
primary  growth  and  the  majority  of  the  glands  have  been  removed, 
the  remaining  glands  may  be  able  to  deal  with,  and,  perhaps,  destroy, 
the  malignant  elements  they  contain;  of  this  process,  however,  we 
know  Uttle  or  nothing." 

Apart  from  the  lymph  nodes,  metastasis  of  gastric  carcinoma 
occurs  most  frequently  to  the  liver,  which  is  affected  in  one-third 
of  cases  examined  at  autopsy.  The  malignant  invasion  occurs  along 
the  radicles  of  the  portal  vein.  In  scirrhous  carcinoma,  and  in  all 
forms  which  cause  marked  pyloric  stenosis,  invasion  of  the  liver  is 
unusual.  The  great  omentum  becomes  invaded  by  cancerous  nodules 
almost  as  frequently  as  the  Hver,  but  ascites  is  a  rather  unusual  ac- 
companiment. The  lungs,  the  intestines,  and  other  internal  organs 
are  as  a  rule  invaded  only  very  late  in  the  disease.  The  left  supra- 
clavicular Ij'mph  nodes  are  sometimes  affected  in  the  last  stages  of 
gastric  carcinoma,  but  it  is  worthy  of  note  that  these  nodes  frequently 
have  been  found  enlarged,  without  being  affected  by  any  cancerous 
change  which  could  be  detected  by  microscopical  examination. 
Smithies  found  metastasis  to  these  nodes  in  11.5  per  cent.,  and  to  the 
rectovesical  pouch  in  16  per  cent,  of  his  cases;  in  all  these  instances 
the  condition  was  inoperable. 

Extension  by  Contigtiity. — Gastric  carcinoma  is  the  most  fre- 
quent cause  of  internal  gastric  fistula.  Of  66  cases  referred  to  by 
Lieblein  and  Hilgenreiner,  in  which  a  gastro-colic  fistula  was  due  to 
disease  of  the  stomach,  it  was  caused  by  carcinoma  in  47.  The 
gall-bladder  is  much  less  often  involved.  In  any  case,  it  is  not  very 
unusual  for  a  fistula  thus  formed  to  close  again  spontaneously  before 
death,  by  the  development  of  further  perigastric  adhesions.  The 
pancreas,   the  liver,  and,   very  rarely,   the  spleen,  may  be  invaded 


Plate  III 


ap. 


^-'^Mtmfi 


Carcinoma  of  Stomach.  Specimen  Secured  by  Partial  Gastrectomy;  the  Ulcerated 
Area  can  be  Seen  where  the  Cardiac  End  of  the  Specimen  has  Been  Turned  Back  like  a 
Cuff.  Note  also  the  Enlarged  Lymphnodes  beneath  the  Pylorus.  iAIhrii^hl.)  Path.  No. 
9251.     Lankenaii  Hospital. 

Face  p.  254 


,^' 


METASTASIS  255 

by  direct  extension  of  the  growth.  Perforation  of  the  diaphragm, 
and  even  the  formation  of  a  gastric  cutaneous  fistula,  is  sometimes 
observed.  Fenwick  refers  to  22  instances  of  this  last  condition,  3 
of  which  came  under  his  own  observation  at  autopsy.  According 
to  Lieblein  and  Hilgenreiner  (1905),  cancer  is  a  more  frecjuent  cause  of 
gastric  cutaneous  fistula  than  is  gastric  ulcer.  They  collected  26 
cases  due  to  the  former,  and  found  only  17  caused  by  ulcer.  The 
reader  is  referred  to  this  valuable  monogrclph  for  further  statistics 
of  gastric  fistulae.     (See  also  p.  398.) 

Perforation  of  gastric  cancer  into  the  free  peritoneal  cavity  is 
very  rare,  existing  in  only  3  per  cent,  of  the  fatal  cases  studied  by 
Fenwick.  Sometimes  a  subacute  perforation  occurs,  with  the  for- 
mation of  a  perigastric  abscess;  and  this,  by  subsequent  rupture,  may 
cause  death  from  peritonitis.  Such  a  case,  recorded  by  the  junior 
author,  has  already  been  described  in  connection  with  Hourglass 
Stomach.     (See  p.  180.) 

Secondary  gastric  carconoma  is  of  little  surgical  interest.  It 
is  found  in  6  or  7  per  cent,  of  autopsies  on  patients  with  gastric  can- 
cer (Hale  White;  Fenwick),  and  is  usually  (73.6  per  cent,  according 
to  Fenwick)  due  to  direct  extension  from  some  neighboring  organ, 
such  as  the  pancreas,  transverse  colon,  gall-bladder,  uterus  (through 
omentum),  esophagus,  etc.;  less  frequently  (21  pr  cent.)  it  is  sec- 
ondary to  cancer  of  the  tongue,  mouth,  pharynx,  upper  esophagus, 
etc.,  being  then  perhaps  due,  as  suggested  by  Klebs,  "to  the  detach- 
ment of  particles  of  growth,  which  are  swallowed,  and  subsequently 
become  engrafted  upon  the  gastric  mucous  membrane."  (Fenwick.) 
Engelhorn  (1097)  called  attention  to  gastric  carcinoma  occurring 
simultaneously  with,  or  secondary  to,  carcinoma  of  the  ovary.  He 
has  studied  13  cases  from  Doderlein's  chnique  and  suggests  the 
propriety  of  examining  the  patient  for  gastric  carcinoma  whenever 
mahgnant  disease  exists  in  the  ovary.  True  metastases  (from  mam- 
mary gland,  testicle,  uterus,  kidney,  etc.)  were  found  in  5  per  cent,  of 
Fenwick's  cases,  and  are  usually  accompanied  by  metastatic  invasion 
of  the  lungs,  liver,  etc.  Hence  surgical  treatment  is  rarely  required 
in  secondary  carcinoma  of  the  stomach. 

One  patient  who  was  operated  on  by  the  senior  author  by  partial 
gastrectomy  for  carcinoma,  returned  30  months  later  with  a  large 
pelvic  tumor.  At  the  operation  this  was  found  to  be  a  solid  tumor  of 
the  ovary;  it  was  thought  to  be  carcinomatous;  but  after  microscopical 
study  Dr.  A.  0.  J.  Kelly  pronounced  it  a  sarcoma.  There  was  no 
recurrence  of  carcinoma  in  the  stomach  or  elsewhere. 


256  CARCINOMA    OF    THE    STOMACH 

Symptoms. — Cancer  of  the  stomach  presents  cHnically  two  forms. 
In  one,  a  patient  past  middle  life,  without  having  suffered  previously 
from  indigestion,  suddenly  loses  appetite,  especially  for  meats,  grows 
progressively  weaker  and  more  emaciated,  develops  epigastric  pain 
and  possibly  a  palpable  mass,  becomes  subject  to  vomiting  spells 
every  few  days,  which  bring  up  a  quantity  of  coffee-ground  material, 
foul  smelling  and  fermented,  and  quickly  develops  the  cancerous 
cachexia.  This  is  the  classical  picture  of  gastric  carcimona  and  it  is 
still  seen;  but  it  is  of  rarity  when  compared  with  the  other  course  of 
development  which  we  have  begun  to  appreciate  only  in  the  last 
decade.  In  the  group  of  cases  studied  by  Smithies  this  rapid  onset 
of  the  disease  was  observed  in  less  than  a  third  of  the  whole  number 
of  patients,  the  average  duration  of  the  symptoms,  before  the  patients 
came  under  observation,  being  7  months. 

The  second,  and  much  more  frequent  course,  is  found  in  patients 
who  have  been  life-long  suff'erers  from  dyspepsia.  Medical  treatment 
has  at  times  given  relief,  but  the  indigestion  recurs  again  and  again. 
Appetite  may  be  preserved,  but  digestion  is  torture;  so  abstemious- 
ness becomes  second  nature.  There  may  or  there  may  not  have  been 
some  period  when  gastric  ulcer  was  suspected  or  actually  diagnosti- 
cated. Usually  there  have  been  no  very  definite  symptoms,  and  the 
patient  has  been  treated  for  chronic  gastritis.  Finally  these  patients 
die,  and  at  autopsy  a  wide-spreading  carcinomatous  ulcer  is  found. 

Although  we  have  pointed  out  the  characteristics  of  the  two  main 
groups  of  cases  in  which  cancer  of  the  stomach  is  found,  it  is  proper  to 
dwell  more  at  length  upon  certain  indi\'idual  symptoms.  And  in  doing 
this,  it  is  well  to  premise  what  is  known  to  all  who  have  anything  to 
do  with  these  patients,  that  early  diagnosis  of  carcinoma  of  the 
stomach  is  so  difficult  as  to  be  usually  impossible;  that  is  to  sa3^  an 
accurate,  assured  diagnosis,  based  en  scientific  reasons,  and  not  a 
mere  supposition  nor  a  happy  guess  that  the  affection  is  mahgnant 
in  nature.  Even  so  distinguished  an  authority  as  Boas  has  come 
to  the  same  melancholy  conclusion. 

The  descriptions  heretofore  given  in  text  books  and  monographs 
on  diseases  of  the  stomach  are  concerned  almost  wholly  with  the 
first,  smaller  group  of  cases,  in  which  the  symptoms  were  subacute 
or  even  acute  in  onset — this  being  the  only  group  of  cases  of  gastric 
cancer  previously  recognized.  But  as  we  have  repeatedly  pointed  out, 
it  is  becoming  more  and  more  widely  appreciated  that  this  class 
forms  only  a  small  proportion  of  all  patients  with  gastric  cancer;  and 
that  the  far  larger  group  will  ultimately  be  found  to  consist  of  those 


SYMPTOMS  257 

patients  who  are  sufferers  from  chronic  gastric  dyspepsia.  These 
patients  present  the  symptoms  already  noted  in  the  section  on  gastric 
ulcer;  and  it  is  needless  to  reiterate  those  symptoms  here.  In  the  first 
group  of  patients,  those  who  present  what  may  be  called  the  classical 
picture  of  cancer  of  the  stomach,  there  are  three  symptoms  which 
stand  out  with  such  distinctness  as  to  be  fairly  characteristic;  these  are: 
pain,  vomiting,  and  the  presence  of  a  tumor.  But  the  pain  and  vomit- 
ing are  not  always  present;  and  they  vary  greatly  in  their  intensity, 
not  only  in  different  patients,  but  in  the  same  patient  at  different 
times.  Nor  should  the  absence  of  a  tumor  be  considered  evidence 
that  the  disease  is  not  cancer.  The  presence  of  a  tumor,  moreover, 
as  already  noted  (p.  80),  is  frequently  due  to  a  purely  inflammatory 
hyperplasia.  So  even  in  this  group  of  cases  where  the  clinical  picture 
is  outUned  with  reasonable  distinctness,  it  is  seen  that  diagnosis  is  no 
such  easy  matter. 

The  pain  in  cancer  of  the  stomach  differs  from  that  of  simple 
ulcer  in  several  ways.  It  is  not  so  sharp  nor  so  localized  a  pain;  it 
is  not  so  invariably  aroused  by  the  ingestion  of  food;  it  is  not  so  regu- 
larly relieved  by  abstinence;  and  it  is  seldom  assuaged  by  a  change 
of  position  or  by  rest.  The  pain  of  cancer  of  the  stomach  is  more 
dull,  aching,  gnawing,  and  constant  than  is  that  of  ulcer;  it  is  more 
often  of  a  tearing,  shooting,  or  darting  character,  when  perigastric 
adhesions  are  dense,  or  when  neighboring  organs  (liver,  diaphragm, 
pancreas;  etc.)  have  been  invaded  by  the  growth. 

The  vomiting  of  gastric  cancer  depends  largely  upon  the  location 
of  the  tumor.  It  usually  will  be  absent  when  the  growth  infiltrates 
the  gastric  walls  widely,  without  obstructing  the  pylorus.  The  evi- 
dences of  cardiac  obstruction  (see  p.  176),  attended  by  great  pain, 
hemorrhage,  and  beginning  cachexia,  are  indicative  of  carcinoma 
in  this  situation.  When  pyloric  obstruction  is  marked,  vomiting 
becomes  frequent.  At  an  earlier  stage  any  indiscretion  in  diet  may 
set  up  an  acute  gastritis,  which,  instead  of  subsiding  as  have  previous 
similar  attacks,  will,  in  the  presence  of  cancer,  persist  in  a  subacute 
or  chronic  form.  This  fact  alone  is  suggestive  of  beginning  cancer. 
As  dilatation  of  the  stomach  increases,  the  vomiting  may  again  become 
less  frequent,  but  at  the  same  time  the  amount  of  vomited  material 
will  become  more  copious,  and  the  evidences  of  stagnation  and  fermen- 
tation will  be  unmistakable.  Close  study  of  the  vomitus,  even  in  the 
early  stages,  will  often  reveal  the  presence  of  minute  quantities  of 
clotted  blood;  and  at  all  stages  of  the  disease,  tests  for  occult  blood 
as  a  rule  will  be  positive.     The  stools  should  always  be  examined  for 

17 


258  CARCINOMA    OF    THE    STOMACH 

occult  blood.  The  negative  value  of  this  test  is  much  greater  than 
its  positive  value,  since,  as  Smithies  says,  when  it  is  positive,  other 
more  easily  obtained  and  more  dependable  signs  and  symptoms  of 
gastric  carcinoma  are  not  lacking.  But  if  the  tests  for  occult  blood 
are  persistently  negative,  cancer  probably  is  absent.  Hematetnesis  is 
rare;  there  is  seldom  so  much  blood  lost  as  to  deserve  this  term;  or 
at  least  even  if  blood  is  lost  in  quantity,  it  usually  is  clotted  before 
being  vomited,  and  then  presents  the  characteristic  coffee-ground 
appearance. 

Tumor  is  not  an  early  sign  in  a  pathological  sense.  It  is,  however, 
not  unfrequently  one  of  the  first  cUnical  evidences  of  the  nature  of  the 
malady.  Search  for  a  tumor  should  be  systematic  and  exhaustive. 
Palpation,  with  the  patient  erect,  supine,  stooping;  and  after  the 
abdominal  walls  have  become  relaxed  by  immersion  of  the  patient 
in  a  hot  bath;  percussion,  with  and  without  distention  of  the  stomach 
or  colon,  or  both,  with  air;  and  finally  complete  emptying  of  the 
stomach — these  should  all  be  tried,  in  the  endeavor  to  ascertain  the 
existence  of  a  tumor.  The  tumor  moves  with  respiration,  and  if  of 
the  pylorus  or  greater  curvature,  often  possesses  some  lateral  mobility 
in  which  case  it  may  be  mistaken  for  an  enlarged  gall-bladder. 
By  fixing  the  tumor  at  the  end  inspiration,  and  holding  it  until 
expiration  is  complete,  it  can  be  felt  to  slide  up  beneath  the  fingers  to 
its  normal  habitat  in  a  characteristic  manner.  A  tumor  on  the  greater 
curvature  becomes  more  evident  when  the  stomach  is  distended;  one 
on  the  lesser  curvature  disappears;  one  at  the  pylorus  is  pushed  up 
beneath  the  liver  if  fixed  by  adhesions,  while  if  free  it  descends  towards 
the  patient's  right.  In  the  presence  of  ascites  it  is  of  course  necessary 
to  draw  off  the  fluid  before  satisfactory  palpation  is  possible. 

In  addition  to  these  three  symptoms,  there  are  three  further 
changes  constantly  present  in  gastric  cancer,  which  may  be  classed 
as  physical  signs:  these  are,  loss  of  weight;  anemia;  and  changes  in 
the  gastric  secretion.  Loss  of  appetite,  especially  for  meats,  arising 
without  apparent  cause,  has  already  been  mentioned  as  a  character- 
istic sign;  and  closely  following  this,  and  caused  as  well  by  the  malig- 
nant growth  itself,  occurs  progressive  loss  of  weight.  To  render  this 
apparent,  the  patient  should  be  regularly  weighed;  it  is  not  sufficient 
to  estimate  the  loss  of  weight  from  the  appearance  of  a  man's  face,  or 
his  visible  emaciation;  the  weight  should  be  recorded  periodically, 
not  oftener  than  twice  a  week,  in  pounds  and  ounces,  care  being  taken 
to  avoid  any  errors  from  changes  in  the  weight  of  clothing.  In 
the  case  of  cancer  it  is  found  practically  without  exception  that  the 


PHYSICAL   SIGNS  259 

loss  of  weight  is  progressive  and  constant,  and  that  no  form  of  dieting 
or  forced  feeding  will  check  the  loss  permanently. 

The  anemia  of  gastric  cancer  is  that  encountered  in  carcinoma 
elsewhere  in  the  body.  Leriche  has  recently  made  the  significant 
statement  that  if  cylindrical  gastrectomy  were  done  more  often  for 
non-stenosing  cancer,  more  cases  of  progressive  pernicious  anemia 
would  be  cured.  (See  Regnault:  "Anemie  pernicieuse  et  cancer 
latent  de  I'estomac."  These  de  Lyon,  1905.)  In  gastric  cancer 
both  the  red  corpuscles  and  the  hemoglobin  are  reduced,  but  rarely 
to  the  extent  that  one  would  be  led  to  expect  from  the  cachexia  pres- 
ent. The  leukocyte  count  is  as  a  rule  constantly  higher  than  normal, 
the  polynuclears  being  increased  at  the  expense  of  the  lymphocytes. 
The  absence  of  hyper-leukocytosis  during  digestion  is  considered  by 
some  nearly  pathogenomonic  of  cancer  of  the  stomach. 

The  gastric  secretion  is  very  constantly  altered  in  the  later  stages 
of  carcinoma  of  this  organ.  Unfortunately  the  characteristic  changes 
are  not  early  enough  Yn  their  occurrence  to  be  of  material  value  in 
reaching  a  diagnosis  for  surgical  purposes.  These  changes  are:  con- 
stant absence  or  marked  diminution  of  the  hydrochloric  acid,  and  the 
presence  of  lactic  acid  and  other  signs  of  fermentation.  These  changes 
are  of  confirmatory  value  if  present,  but  if  not  present,  no  import 
need  be  attached  to  their  absence.  In  carcinoma  developing  on  ulcer, 
hydrochloric  acid  is  apt  to  persist;  and  the  fermentation  signs  may 
equally  well  be  present  in  stagnation  from  benign  disease.  In  normal 
stomachs  the  amount  of  hydrochloric  acid  gradually  increases  after  the 
ingestion  of  food;  in  cancer,  no  matter  how  small  in  quantity  at  the  first 
test  after  a  meal,  repeated  tests  show  that  the  amount  grows  rapidly 
less,  instead  of  increasing  in  cjuantity  (Gluzinsky's  test).  Detection,  by 
means  of  Esbach's  reagent,  of  albumen  (nucleo-albumen  and  mucin) 
in  the  washings  from  a  fasting  stomach,  after  excluding  the  possibiHty 
of  albumen  being  present  from  previously  ingested  food,  speaks  in 
favor  of  carcinoma  (Salomon's  test).  Recently  this  test  has  been 
largely  supplanted  by  the  test  of  Wolft'  and  Junghans.  Smithies 
reports  the  Wolft'- Junghans  test  positive  in  80  per  cent,  of  230  cases  of 
gastric  carcinoma;  but  he  notes  that  it  proved  positive  also  in  a  large 
proportion  of  cases  of  simple  gastric  or  duodenal  ulcer  (66  to  78  per 
cent.)  especially  when  these  were  accompanied  by  pyloric  stenosis  "or 
gastric  atony. 

Diagnosis  of  carcinoma  in  its  early  stages  by  means  of  a  hemolytic 
blood  test  has  been  attempted  by  Kelling,  Crile,  and  others.  Wideroe 
(1908)  applied  Kelling's  test  in  50  cases,  using  hen's  blood  exclusively: 


26o  CARCINOMA   OF   THE    STOMACH 

25  of  these  patients  had  cancer,  and  25  suffered  from  other  diseases. 
He  found  that  64  per  cent,  of  the  cancer  cases  gave  positive  results; 
6  of  the  9  patients  in  whom  the  test  was  negative  were  already  cachectic, 
this  fact  supporting  Kelling's  contention  that  the  hemolysis 
diminishes  with  advancing  debility.  In  the  patients  not  having 
cancer,  the  hemolysis  surpassed  30  per  cent,  in  only  three  cases,  and  in  2 
of  these  there  was  a  disease  of  the  blood;  in  the  patients  with  cancer, 
however,  the  degree  of  hemolysis  varied  from  50  to  85  per  cent.  Paus, 
testing  the  blood  of  90  patients,  obtained  a  positive  reaction  in  65  per 
cent,  of  those  in  whom  the  course  of  the  disease  or  operation  confirmed 
the  diagnosis  of  cancer.  Crile  (1908)  found  no  hemolysis  in  107  normal 
individuals.  Among  50  diseased  persons,  not  suffering  with  cancer, 
the  test  was  positive  in  only  4  (i  with  hemoglobinuria,  i  with  eclampsia, 
I  with  hematuria,  and  i  with  undiagnosed  gastric  lesion),  while  among 
50  carcinomatous  patients,  39  presented  hemolysis;  and  13  out  of  16 
sarcomatous  patients  presented  hemolysis.  In  all  patients  with  malig- 
nant disease  who  did  not  present  hemolysis,  the  disease  was  advanced. 
Kelling  (1914)  using  an  improved  method  for  the  test  obtained  a  pos- 
tive  result  in  90  per  cent.  (58  out  of  65)  of  cases  of  carcinoma  of  the 
alimentary  canal.  He  advocates  controlhng  the  hemolytic  blood  test 
by  means  of  Ascole's  meiostagmin  reaction,  since  these  two  tests  have 
different  sources  of  error.  If  both  reactions  are  distinctly  positive, 
the  correctness  of  the  diagnosis  is  all  the  more  certain. 

Fluoroscopy  has  been  much  employed  in  the  diagnosis  of  carcinoma 
of  the  stomach;  but  as  noted  in  Chapter  III,  where  the  subject  of  the 
X-ray  diagnosis  of  gastric  legions  is  discussed,  there  are  many  sources  of 
error,  and  even  expert  radiologists  are  not  unanimous  in  their  belief 
in  the  infallibility  of  the  method. 

Diagnosis. — It  may  now  be  asked:  If  the  symptoms  are  so  in- 
definite, the  physical  signs  so  misleading,  and  both  of  such  late  de- 
velopment, how  is  a  diagnosis  to  be  reached  in  time  for  surgery  to  be  of 
any  avail?  This  is  a  pertinent  question;  and  to  find  a  conscientious 
answer  is  the  sorry  duty  of  the  surgeon.  It  will  not  do  to  lay  the  onus 
of  this  task  on  the  physician;  if  cancer  of  the  stomach  is  a  surgical 
disease,  the  surgeon  should  be  able  to  reach  a  reasonably  correct 
diagnosis.  Boas  diagnosed  sixty  cases  of  gastric  cancer  within  three 
months  of  the  appearance  of  the  first  symptoms  of  the  disease.  He 
found  that  of  these  only  three  (5  per  cent.)  could  be  treated  by  resection 
of  the  growth;  that  thirteen  were  suitable  for  gastro-enterostomy;  and 
that  two  could  only  be  explored.  Of  127  cases  diagnosed  within  six 
months  of  the  appearance  of  first  s3^mptoms,  Boas  found  that  only 


DIAGNOSIS  261 

eight  (6.3  per  cent.)  were  suitable  subjects  for  resection.  From  this 
experience  Boas  came  to  the  conclusion  that  the  early  diagnosis  of 
gastric  cancer  is  at  present  usually  impossible;  that  the  constant  moan 
of  surgery  that  patients  are  not  sent  early  enough  for  operation,  is  not 
warranted  by  the  facts;  and  that  those  patients  who  encounter  the 
question  of  operability  more  than  six  months  after  the  first  onset  of 
symptoms  afford  a  greater  hope  of  radical  cure  than  do  the  earlier 
cases.  But  Hoffmann,  in  Mikulicz's  clinique,  found  that  of  117 
cases  diagnosticated  within  three  months  of  onset,  twenty-four  (20.8 
per  cent.)  could  be  treated  by  resection;  and  of  193  cases  whose  first 
symptoms  dated  back  six  months  to  one  year,  he  found  fifty-eight 
(30.3  per  cent.)  could  be  treated  by  resection.  This  discrepancy  be- 
tween the  surgical  and  medical  statistics  is  not  due  to  the  fact  that 
Mikulicz  allowed  wider  limits  to  the  indications  for  radical  operation; 
but  because  the  worst  cases  go  to  the  physician  and  the  more  operable 
ones  go  directly  to  the  surgeon.  Moreover,  the  patients  seen  by  medi- 
cal men  are  either  hospital  out-patients,  or  those  in  private  practice — 
the  number  is  great,  but  the  patients  do  not  remain  long  under  observa- 
tion; they  pass  on  to  another  clinique. 

It  has  been  true  in  the  past,  but  it  is  now  much  less  true,  at  least 
of  progressive  physicians,  that  they  did  not  send  the  patients  early 
enough  to  the  surgeon.  The  surgeon  should  be  called  in  consultation 
as  soon  as  an  anatomical  cause  for  the  gastric  disease  is  recognized,  and 
in  obscure  cases  he  should  be  consulted  even  before  this  stage  of  accu- 
racy in  diagnosis  has  been  reached.  Likewise,  when  gastric  cases 
come  directly  to  the  surgeon,  he  is  only  too  glad  to  have  the  opinion 
of  his  medical  colleagues,  and  to  avail  himself  of  such  aids  as  the  clinical 
laboratory  can  afford.  But  he  has  been  the  first  to  recognize  that,  as 
all  signs  fail  in  dry  weather,  so  the  possibility  of  reaching  an  accurate 
diagnosis  must  be  postponed  in  certain  instances  until  the  patient  will 
be  beyond  the  help  of  surgery.  Under  such  circumstances,  and  when 
there  is  undoubtedly  some  actual  anatomical  lesion  of  the  stomach, 
even  though  an  exact  pathological  diagnosis  of  the  lesion  has  not  been 
reached,  but  because  it  is  evident  that  only  some  form  of  surgical 
operation  will  be  of  any  avail  in  curing  the  disease — under  these  cir- 
cumstances, we  repeat,  we  believe  exploratory  operations  should  be 
undertaken.  We  do  not  advocate  exploration  as  a  therapeutic  test; 
we  do  not  say,  do  gastro-enterostomy  for  pain  in  the  stomach  and  if  the 
result  is  favorable  conclude  that  the  disease  was  gastric  ulcer,  and  if  the 
patient  dies  assert  that  death  was  clearly  due  to  the  cancerous  cachexia; 
nor  do  we  counsel  exploration  merely  because  it  is  easier  for  the  surgeon 


262  CARCINOMA   OF   THE   STOMACH 

and  possibly  less  distasteful  to  the  patient  than  careful  examination 
and  repeated  study  of  the  disease  by  other  means.  Yet  it  is  our  belief 
that  in  the  vast  majority  of  patients  with  gastric  disorders  a  diagnosis 
of  sufi&cient  accuracy  can  be  reached  before  operation  is  undertaken 
thoroughly  to  justify  the  operation  when  done.  We  are  convinced, 
moreover,  that  if  chronic  and  rebelhous  cases  of  indigestion  were  more 
promptly  turned  over  to  the  surgeon,  and  if  suitable  operations  were 
done  on  such  patients,  there  would  be  fewer  cases  of  carcinoma  of  the 
stomach  observed  by  physicians.  It  seems  to  us  that  every  case 
diagnosticated  certainly  as  carcinoma  of  the  stomach  before  operation 
is  a  disgrace  to  the  attending  physician,  provided  he  has  had  the  patient 
under  treatment  for  more  than  a  few  weeks.  In  that  space  of  time  it  is 
at  present  usually  impossible  to  render  absolute  the  diagnosis  of  a  gastric 
carcinoma  while  still  in  the  operable  stage;  but  it  is  entirely  possible 
and  we  contend  with  all  earnestness  that  it  should  be  done  to  reach 
within  that  time  the  conclusion  that  an  anatomical  basis  for  the  symp- 
toms exists,  and  that  this  can  be  removed  only  by  operative  means. 

In  recapitulation,  then,  it  may  be  said  that  the  presence  of  can- 
cer should  be  suspected  when  chronic  gastric  catarrh  exists  without 
any  discoverable  cause  (such  as  abuse  of  food,  of  alcohol,  of  drugs; 
circulatory  disturbances  of  the  heart  or  Uver;  or  diseases,  such  as 
gall  stones,  gastric  ulcer,  etc.,  wliich  would  cause  some  definite  lesions 
in  the  region  of  the  stomach),  especially  if  this  chronic  gastritis  be 
in  a  patient  over  forty  years  of  age,  and  if  it  be  attended  by  loss  of 
appetite  for  meats  (Kocher).  If  a  tumor  exists,  the  diagnosis  is  less 
difficult;  but  the  tumor  must  be  distinguished  from  a  distended  gall 
bladder,  from  a  growth  of  the  colon,  of  the  pancreas,  etc.  In  obscure 
cases  distension  of  the  stomach  with  air  should  never  be  neglected; 
this  may  render  a  hidden  tumor  palpable,  and  the  characteristic 
pyramidal  shape  of  a  pyloric  growth  (apex  toward  the  duodenum  and 
indistinct  base  toward  the  body  of  the  stomach)  can  frequently  be 
recognized  (Kocher).  Occult  blood  in  the  stomach  contents  and  feces 
is  the  most  valuable  of  the  laboratory  findings.  In  non-malignant 
ulcerations  of  the  stomach,  rest  in  bed  with  milk  diet  will  cause  the 
disappearance  of  occult  blood.     In  cancer  no  treatment  Jias  any  effect. 

In  cases  where  the  stomach  affection  resists  medical  treatment, 
exploratory  operation  is  indicated.  This  is  not  always  satisfactory', 
nor  is  it  always  possible,  even  by  the  senses  of  touch  and  sight,  to  make 
a  positive  diagnosis  of  carcinoma.  Fortunately,  the  benefit  is  gen- 
erally given  to  the  patient  and  the  diseased  portion  of  the  stomach 
removed   when  practicable,   on   the   supposition   that   malignancy  is 


PROGNOSIS  263 

present.  Many  of  the  most  experienced  operators  have  been  mis- 
led by  the  conditions  present,  the  true  condition  of  affairs  not  being 
realized  until  the  excised  part  of  the  stomach  was  subjected  to  micro- 
scopical examination.  If  a  distinct  tumor  is  present,  it  can  generally 
be  recognized  as  carcinomatous  by  its  irregular  shape;  by  its  "  knotty" 
feel;  by  diffused  induration  into  the  surrounding  structures.  Before 
there  is  tumor  formation  of  any  moment,  it  is  nearly  always  impossible 
to  differentiate  between  the  thickening  and  induration  consequent 
upon  inflammation  and  that  due  to  malignancy.  While  it  is  true  that 
the  mortahty  following  posterior  gastro-jejunostomy  in  benign  disease 
is  lower  than  that  following  gastrectomy,  it  is  always  justifiable  and 
in  the  opinion  of  some  surgeons,  mandatory,  to  subject  the  patient  to 
the  latter  risk  rather  than  to  the  surely  fatal  results  of  an  undisturbed 
maUgnant  condition,  if  such  be  present.'  If  there  were  involvement  of 
the  lymph  glands  with  metastasis  to  any  of  the  neighboring  viscera 
the  diagnosis  of  malignancy  would  be  unquestioned;  without  these 
complications  or  extensions,  in  the  absence  of  the  more  or  less 
characteristic  tumor  formation,  the  diagnosis  must  be  tentative  until 
a  final  appeal  can  be  made  either  to  the  microscope,  if  the  affected 
portion  of  the  stomach  be  removed,  or  to  the  extension  of  the  disease 
if  it  be  allowed  to  remain  in  situ.  Even  a  microscopical  diagnosis  is 
occasionally  in  error.  If  the  freezing  microtome  is  used  to  facilitate 
diagnosis  during  an  operation,  the  surgeon's  duty  of  course  is  to  do  a 
radical  operation,  when  possible,  if  the  report  from  the  pathologist  is 
positive;  but  if  negative,  he  must  rely  solely  on  the  clinical  diagnosis. 
Prognosis. — Though  medical  means  are  powerless  to  cure  cancer 
in  any  region  of  the  body,  yet  no  one  would  be  so  foolish  as  to  deny 
that  in  cases  of  inoperable  tumors  much  may  be  accompHshed  to 
prolong  hfe  and  to  mitigate  suffering.  Tyson  said  he  was  quite  sure 
that  a  great  deal  more  could  be  done  in  this  way  than  was  commonly 
thought  possible.  The  wide  experience  of  Jacobi  (1906),  so  cautiously 
and  conservatively  expressed,  in  regard  to  the  beneficial  effect  of 
methylene  blue  (methylthionin  hydrochloride)  in  such  patients,  is 
a  gratifying  example  of  what  may  be  done  by  medical  science  even 
for  hopeless  cases.  But,  as  Bland  Sutton  said  a  number  of  years  ago, 
as  long  as  we  are  ignorant  of  the  cause  of  cancer,  so  long  must  the 
only  successful  treatment  be  the  extirpation  of  the  growth. 

'  Thus  Moynihan  (1920)  points  out  that  the  mortality  from  the  later  development 
of  carcinoma,  in  Paterson's  cases  of  gastro-jejunostomy  for  supposedly  benign  disease,  is 
as  great  as  would  have  been  that  from  primary  gastrectomy  which  would  have  cured  the 
patient  once  for  all. 


264 


CARCINOllA    OF    THE    STOMACH 


It  is  sometimes  questioned  by  physicians,  whether  surgery  can 
really  accompUsh  more  in  prolonging  life  than  can  medical  measures. 
It  is  sometimes  doubted  whether  surgery  can  ever  effect  a  cure.  To 
answer  these  questions  surgeons  must  show  the  ultimate  results  of 
their  operations.  They  must  trace  their  patients  for  a  period  at  least 
of  three  years  after  operation,  and  report  their  actual  condition  at 
the  end  of  that  time.  But  before  the  duration  of  life  and  the  prospect 
of  ultimate  cure  after  surgical  operation  are  discussed,  and  even  before 
a  comparison  is  made  with  the  expectation  of  hfe  and  the  certainty  of 
ultimate  death  from  the  disease  which  are  necessary  attendants  upon 
purely  medical  treatment;  before  these  interesting  questions  are  dis- 
cussed, we  repeat,  it  is  expedient  to  study  the  immediate  dangers  of 
the  operations  which  surgeons  are  urging  in  the  treatment  of  this 
disease. 

The  mortality  and  the  ultimate  results  of  operations  for  benign 
gastric  disease  have  already  been  considered  in  detail  (pp.  loi,  105). 
The  results  of  such  operations,  which  may  be  considered  in  the  Hght 
of  preventive  operations  for  cancer,  should  be  compared  with  the 
following  figures  of  operations  undertaken  for  the  cure  of  this  disease. 

Partial  Gastrectomy  for  CARcrN'OMA 


Operator  and  Reference 


Cases     Deaths 


Altschul  (Beitr.  z.  klin.  Chir.,  1913,  Ixx.xiv,  421) 

Bindseil  (Inaug.  Diss. ,  Giessen,  1 91 2) 

Deaver  (Records  ofLankenau  Hospital,  Philadelphia,  to  1920) 

Deloreand  .-Mamartine  (Lyon  Chir.,  1909,  ii,  281) 

Delore  and  Santy  (Lyon  Chir.,  1914,  xi,  iij)  1908-11 

191 1-13 

Feurer  (Deutsch.  Zeit.  f.  Chir.,  1912,  c.wi,  69) 

Galpern  (Centr.  f.  Chir.,  1914,  xli,  1390) 

Gar  (Centr.  f.  Chir.,  1912,  xxxix,  1276) 

V.  Haberer  (VVien.  med.  Woch.,  1912,  Ixii,  3089) 

Kiittner  (Therap.  d.  Gegenwart,  191 1,  liii,  19)  (Collected 
statistics  from  Breslau) 102 

Mayo  Clinic  (Annals  of  Surg.  1919,  ii,  236)  (1897-1919) 736 

Jlikaye  (in  Jour.  Am.  ^led.  Assoc,  1914,  Ixxii,  2051) 116 

Sherren  (Practitioner,  1914-15,  xciii,  463) 27 

T^moin  (.Ann.  internat.  de  Chir.  Gastro-Intcst.,  loii,  v,  44) 

Collected,  1898-1909 .      168 

Before  1908 91 

190S-1909 ;       77 

Weil  (Berl.  klin.  Woch.,  1913,  i,  390) 13S 


1 48 

26 

8 

12 

14 

3 

I 


25 

lOI 

34 
3 

50 
3S 
12 


Mortality 
per  cent. 


50.0 
40.6 
21 .0 
26.0 

32s 
16.6 

3-2 

19.0 
12 .0 
28.0 
10.0 

24.0 

13-7 
29.2 

"■3 

30.0 
41-7 
15s 

-30 


PROGNOSIS  265 

This  gives  a  total  of  1580  partial  gastrectomies  for  carcinoma,  with 
421  deaths,  or  a  mortality  of  more  than  26  per  cent.,  as  the  immediate 
result  of  operations  for  the  cure  of  this  disease.  If  an  early  diagnosis 
is  made,  and  the  patient  is  in  good  general  condition,  the  mortality 
is  much  lower.  Many  surgeons  have  a  series  of  from  10  to  20  opera- 
tions without  a  death.  But  the  natural  and  proper  desire  to  extend 
the  hmits  of  operability,  while  it  benefits  the  patients  who  survive, 
serves  inevitably  to  keep  the  operative  mortality  at  the  high  rate 
just  mentioned.  This,  it  will  be  remembered,  is  to  be  contrasted  with 
an  immediate  mortality  of  about  5  or  10  per  cent,  after  operations 
which  may  be  regarded  as  preventative  of  the  development  of  car- 
cinoma (p.  lOl). 

It  will  next  be  proper  to  determine  what  proportion  of  the  three- 
fourths  of  patients  who  survive  gastrectomy  may  reasonably  hope  to 
be  ultimately  and  permanently  cured  of  their  disease.  Let  it  not  be 
forgotten  that  over  70  per  cent,  of  patients  surviving  the  prophylactic 
operation  (for  benign  disease  of  the  stomach)  have  been  proved  to 
be  ultimately  cured.  Robson  and  Moynihan  in  1904  studied  the 
statistics  bearing  on  this  point  from  the  cliniques  of  Kronlein  and 
Mikulicz;  Kausch  (1907)  tabulated  the  results  of  Czerny  and  Kocher. 
From  all  these  sources  it  is  evident  that  patients  suffering  with  gastric 
carcinoma  have,  under  medical  treatment,  an  expectation  of  Hfe  of 
about  twelve  months  from  the  beginning  of  the  disease.  Many 
writers  put  it  at  less.  Not  only  is  this  the  duration  of  life,  but  it  should 
not  be  forgotten  that  at  the  end  of  that  time  the  patients  under  medical 
treatment  will  all  be  dead.  There  will  not  be  even  one  among  those 
treated  medically  who  at  the  conclusion  of  that  period  will  have  had  up 
to  that  time  no  recurrence  of  a  malignant  tumor  successfully  removed 
by  operation,  and  who  may,  therefore,  still  be  considered  as  curable — 
as  potentially  cured.  If,  then,  surgery  can  show  any  permanent 
cures,  and  if  the  average  duration  of  life  under  surgical  treatment  is 
longer,  or  at  least  not  less  than  that  under  medical  treatment,  the 
conclusion  surely  is  justified  that  surgical  intervention  is  best  for 
these  patients.  The  question,  in  fact,  is  not  "Is  operation  a  sure 
cure  for  gastric  cancer?"  but  ''Does  anything  else  offer  even  the 
shadow  of  a  chance?"  Did  not  Celsus  write:  ''  Nihil  interest  an 
satis  tutum  sit  prcesidimn,  quod  unicum  est?"  Even  if  the  surgeon 
is  aware  that  one  out  of  four  patients,  or  four  out  of  sixteen  patients, 
on  whom  he  operates  for  gastric  cancer  will  surely  die,  he  should  not 
therefore  hold  his  hand,  and  thereby  condemn  the  whole  series  to 
certain  death  in  about  a  twelve-months'  time.     If  he  could  say  with 


266  CARCINOMA   OF    THE    STOMACH 

certainly  to  liimself,  "I  have  had  three  recoveries  from  gastrectomy; 
this  is  my  fourth  patient,  and  he  is  therefore  sure  to  die  from  the 
operation" — under  such  circumstances,  of  course,  no  surgeon  would 
be  justified  in  operating.  But  this  is  not  the  way  to  argue  from  statis- 
tics; for  this  surgeon  with  equal  justice  might  have  said  to  himself  in 
the  beginning,  "This  is  my  first  patient  for  gastrectomy;  even  though 
the  three  following  patients  should  recover,  this  first  one  will  surely 
die;  I  will  therefore  refuse  to  operate  for  fear  of  killing  Irim."  Statis- 
tices  are  a  valuable  guide  to  prognosis  for  those  who  know  how  to  use 
them;  and  no  surgeon  can  justifiably  undertake  an  operation  which 
he  is  convinced  will  kill  his  patient;  but  by  employing  that  most 
precious  quality  of  mind  known  as  judgment,  and  by  selecting  the 
patients  who  are  suited  for  the  operation  in  question,  the  skillful 
surgeon  is  enabled  to  save  many  lives  otherwise  doomed  to  destruction. 
What,  then,  is  the  prognosis  in  regard  to  prolongation  of  life  by 
operation?  Moynihan  studied  the  average  duration  of  life  in  patients 
who  underwent  gastrectomy  in  the  cliniques  of  Kronlein  and  Mikuhcz; 
he  found  that  from  the  beginning  to  the  end  of  the  disease  it  was  as 
much  as  twenty-four  to  twenty- five  months,  or  more  than  twice  as 
long  as  the  average  duration  of  Ufe  without  operation.  Paterson's 
figures  from  collective  statistics  give  the  duration  of  Hfe  after  operation 
(86  operations  in  all)  as  an  average  of  nineteen  months  after  total  gas- 
trectomy (17  patients),  of  twenty-two  and  a  half  months  after  subtotal 
gastrectomy  (14  patients),  and  of  just  over  two  years  after  partial  gas- 
trectomy (55  patients).  Kausch  report  an  average  duration  of  life 
after  operation  of  18.3  months  in  Mikulicz's  patients,  of  18.7  months 
in  Kocher's  patients,  and  of  18  months  in  Kronlein's  patients.  It 
should  be  noted  that  Moynihan's  figures  refer  to  duration  of  life  after 
the  appearance  of  symptoms  of  gastric  cancer,  while  Paterson's  and 
Kausch's  refer  only  to  the  duration  of  life  after  operation.  With  this 
allowance,  it  is  seen  that  the  figures  agree  very  closely;  and  as  they  are 
gathered  from  very  different  sources  (Moynihan's  and  Kausch's  from 
the  German  cliniques,  and  Paterson's  largely  from  British  sources), 
each  series  serves  to  confirm  the  other.  Now  if  these  patients  had  not 
been  operated  on,  the  duration  of  liie  from  the  beginning  of  the  disease 
(not  from  the  date  of  operation)  would  have  been  at  most  one  year, 
probably  less.  Thus,  as  we  have  elsewhere  pointed  out,  not  only  is 
life  considerably  prolonged,  but  at  the  end  of  this  period  a  number  of 
patients  are  still  Uving  and  in  good  health;  whereas  if  no  operation  had 
been  done,  they  would  all  of  them  have  been  dead  before  this  time 
was  reached. 


PROGNOSIS  AFTER   GASTRECTOMY 


267 


Moreover,  not  only  may  the  mere  addition  to  the  patient's  life  be 
of  utmost  importance  from  a  social,  commercial,  or  financial  point  of 
view,  but  death,  when  it  does  come,  will  attack  the  sufferer  in  a  less 
hideous  form.  The  patient  will  not  die  of  starvation,  as  he  would  have 
done  had  no  operation  been  performed.  And  although  it  would  be 
heartless  in  the  surgeon  to  tell  his  patient,  when  urging  operation,  that 
even  if  the  chance  of  permanent  cure  is  slight,  it  is  nevertheless 
altogether  hkely  that  he  will  die  of  cancer  of  the  Uver,  with  its  attend- 
ant cachexia,  and  not  from  progressive  starvation — although,  we  re- 
peat, to  draw  such  a  picture  of  the  future  for  his  unfortunate  patient 
would  be  diaboUcally  cold-blooded  in  the  surgeon,  yet  we  doubt  not 
that  many  a  patient,  dying  of  the  cancerous  cachexia  some  two  years 
after  the  operation,  will  daily  bless  the  art  of  surgery  which  has  so  pro- 
longed his  life  and  mitigated  his  suffering  during  the  gradual  approach 
of  death. 

But,  though  the  chances  of  permanent  cure  are  slight,  they  are  not 
altogether  imaginary.  Compare  the  following  tables:  the  first  is 
reproduced  from  the  first  edition  of  this  work,  while  the  second  repre- 
sents statistics  pubhshed  since  that  date  (1909). 

The  statistics  from  the  Mayo  Chnic,  published  in  19 19  by  C.  H. 
Mayo,  are  probably  the  most  extensive  on  record:  not  only  did  37.6  per 
cent,  of  patients  who  survived  partial  gastrectomy  show  "three-year 
cures,"  but  of  234  patients  traced  for  more  than  5  years  after  operation 
no  less  than  59  (25  per  cent.)  were  still  alive  and  well  after  a  period  of 
5  years.  But  though  these  figures  are  very  encouraging  on  their  face, 
it  is  perhaps  well  to  recall  that  the  diagnosis  of  carcinoma  in  these  cases 
presumably  was  based  on  the  histological  reports  of  pathologists  whose 


End  Results  of  Partial  Gastrectomy  for  Carcinoma  (1909) 


Operator 


Cases_ without  recurrence  after  three  years 


No.  of 
patients 

Per  cent. 

of 

Per  cent,  of 

whole  no.  of 
operations 

those  who  sur- 
vived operation 

2 

6^5 

33 

38.3 

6 

20.0 

330 

18 

19-3 

26.0 

2 

7.0 

10. 0 

17 

14-3 
14.0 

24.0 

Braun  (cited  by  Creite) 

British  surgeons  (cited  by  Paterson) 

Czemy  (cited  by  Kausch) 

Kocher  (Corr.  Bl.  f.  Schw.  Aerzte,  1907, 

xxxvii,  265) 

Kroniein  (cited  by  Kausch) 

Mikulicz  (cited  by  Kausch) 

Robson  (cited  by  Kausch) 


268  CARCINOMA    OF    THE    STOMACH 

End  Resclts  of  Partial  Gastrectomy  for  Carcinoma  (since  igog) 


Operator 


Altschul  (Beitr.  z.  kl.  Chir.,  1913,  Ixxxiv, 

42t) 

Bindseil  (Inaug.  Dissert.,  Giessen,  1912) 
Boeckel  (Strassb.  med.  Zeitschr.,  1910, 

vii,  323) 

Deaver  (Records  of  Lankenau  Hospital) . 
Feurer  (Deutsch.  Zeit.  f.   Chir.,   191 2, 

c.xvi,  69) 

Hartmann  (Presse  Med.  1919,  245) 

Kuttner  (.\rch.  f.  klin.  Chir.,  1914,  cv, 

789) 

Mayo,  C.H.(  Annals  of  Surg.,  i9i9,ii,  236) 
Sherren  (Practitioner,  1914,  xciii,  463).. 
Temoin  (Ann.  Internat.  de  Chir.  Gastro- 

intest.,  1911,  V,  44) 

Weil  (Berl.  klin.  Woch.,  1Q13,  I,  390.  .  . 


Cases  without  recurrence  after  three  years 


Per  cent,  of     j     Per  cent,  of 
whole  no.  of    1  those  who  sur- 
operations       vived  operation 


64 
5 

2 

4 

9 
9 

30 

115 

S 

33 

S 


8.0 

21.0 

13.0 

16.6 

18.8 

28. s 

12-5 

17-3 

15   4 


18.0 
26.9 
18. s 

19.6 
10.8 


26.0 
37-6 
20.8 

26.9 
13-7 


findings  are  in  dispute.  It  should  further  be  remarked  that  not  all  of 
the  specimens  removed  by  Temoin,  whose  figures  are  quoted  above, 
were  examined,  and  that  not  all  of  those  which  were  examined  proved  to 
be  carcinomatous. 

Possibly  still  further  statistics  might  be  quoted;  but  those  already 
given  are  sufficient  to  show  that  wc  may  expect,  at  present,  about  10 
or  15  per  cent,  of  patients  treated  by  gastrectomy  to  be  permanently  cured 
without  liability  of  recurrence. 

There  is  still  another  question  of  interest  in  regard  to  prognosis. 
That  is  the  ratio  of  operable  cases  to  the  whole  number  of  patients 
seen.  W.  J.  Mayo  writes  (1913):  "It  may  be  said  that  with  our 
present  means  of  diagnosis,  cancer  of  the  pyloric  end  of  the  stomach  may 
be  recognized  sufficiently  early  to  perform  the  radical  operation  in  at 
least  half  the  cases."  This  is  certainly  a  much  higher  proportion  than 
indicated  by  the  statistics  published  in  the  first  edition  of  this  work, 
which  showed  that  up  to  that  time  surgeons  had  found  that  only  in 
from  5  to  30  per  cent,  of  these  patients  was  it  possible  to  do  a  radical 
operation. 

What  shall  the  surgeon  do  with  those  patients  in  whom  the  disease 
is  so  far  advanced  as  to  forbid  a  radical  operation?  In  other  words, 
do  palliative  operations  prolong  life  and  add  to  the  patient's  com- 


THE   QUESTION    OF    PALLIATIVE    OPERATIONS  269 

fort?  Until  operation  is  more  frequently  undertaken  in  the  very 
early  stages  of  the  malady,  gastro-jejunostomy  must  still  be  the  opera- 
tion most  often  adopted.  Most  of  the  operations  of  gastrectomy  in  our 
own  hands  have  been  on  patients  in  whom  the  existence  of  malignant 
disease  was  merely  suspected,  but  not  certainly  known,  before  the  ab- 
domen was  opened.  A  palpable  tumor  felt  before  operation  will 
naturally  suggest  cancer;  but  the  case  reports  already  referred  to 
(see  p.  114),  in  which  such  masses  have  been  known  to  disappear 
after  gastro-enterostomy,  prove  that  all  palpable  tumors  are  not  car- 
cinomatous in  nature.  As  has  been  urged  elsewhere,  it  is  in  this  class 
of  patients  that  exploratory  laparotomy  finds  its  most  legitimate 
field.  There  was  only  4  operative  deaths  (3  from  shock  and  i  from 
uremia)  among  the  last  39  exploratory  operations  undertaken  by  the 
senior  author  at  the  Lankenau  Hospital  (mortality  of  slightly  over  10 
per  cent.).  C.  H.  Mayo  (1919)  reports  from  the  Mayo  Clinic  746 
explorations,  with  an  immediate  mortality  of  2.9  per  cent.;  while 
Altschul's  figures  give  139  explorations  with  15  deaths  (10.8  per  cent.). 
The  statistics  from  the  cliniques  of  Kronlein  and  MikuUcz,  studied  at 
length  by  Moynihan,  show  that  patients  who  had  undergone  an  ex- 
ploratory laparotomy  in  which  no  further  operative  treatment  was 
possible,  actually  lived  longer  than  did  those  whose  disease  was  so  far 
advanced  as  to  make  even  an  exploration  unjustifiable,  or  those  who 
entirely  refused  an  operation  of  any  kind.  In  very  many  operations, 
moreover,  which  are  commenced  as  explorations  merely,  it  is  found 
possible  either  to  remove  the  growth,  or  at  least  to  perform  a  palliative 
operation  which  will  materially  prolong  life  and  relieve  suffering. 
This,  after  all,  and  not  the  production  of  statistics,  is  the  end  and  object 
of  surgery. 

Gastro-jejunostomy  for  carcinoma  is  naturally  attended  by  a  larger 
mortality  than  are  similar  operations  for  benign  disease.  The  tables 
published  in  the  first  edition  of  this  work  indicated  a  death  rate  at  that 
time  varying  from  15  to  over  40  per  cent.,  the  average  death  rate  being 
about  30  per  cent.  It  is  probable  that  some  reduction  in  mortality  has 
been  secured  in  recent  years.  The  figures  from  the  Mayo  Clinic 
(1919)  give  612  palUative  operations  of  various  kinds,  with  a  mortahty 
of  II. I  per  cent.;  Altschul  (1913)  reported  193  gastro-jejunostomies  for 
gastric  carcinoma, with  54  deaths  (27.9  per  cent.).  The  senior  author  has 
adopted  gastro-jejunostomy  for  carcinoma  of  the  stomach  in  50  pa- 
tients during  the  last  10  years  (1909-1919):  of  these  patients  7  died, 
an  operative  mortality  of  14  per  cent. 

The  following  case  history,  of  a  patient  who  came  under  the  care  of 


270  CAK.CINOM.A.    OF    THE    STOMACH 

the  junior  author  some  years  ago  at  the  Episcopal  Hospital,  shows  the 
insidious  manner  in  which  a  carcinoma  of  the  stomach  may  grow  to 
inoperable  size  even  when  the  patient  is  under  medical  observation; 
it  also  is  an  example  of  the  striking  if  temporary  improvement  often  seen 
when  gastro-jejunostomy  is  adopted  in  cases  of  obstruction. 

Insidious  Onset  of  Carcinoma  of  Stomach;  Gastro-jejunostomy 

FOR  Obstruction;  Patient  Resumed  Active  Work 

FOR  6  Months 

Charles  G.,  52  years  of  age,  farmer  by  occupation. 

March  21,  igi5.     Admitted  to  the  Episcopal  Hospital,  Dr.  Stevens'  Service. 

Lobar  pneumonia  (right),  duration  one  week. 

Abdominal  examination:  Entire  epigastrium  is  held  somewhat  rigid  and  there  is  sore- 
ness on  deep  pressure.     No  abnormal  masses  are  felt. 

Has  large  reducible  hernia  on  left  side;  wears  truss. 

March  30.     Discharged— recovered. 

December  lo.  Readmitted  to  the  ^ledical  Ward  (Dr.  Piersol's  Service).  Two  days 
ago,  while  in  usual  health,  while  leading  a  horse,  became  dizzy,  fell  and  was  unable  to  rise, 
because  of  weakness.  Never  dizzy  before.  Taken  home  in  cart.  No  pain,  no  paralysis, 
no  vomiting,  but  he  had  had  a  bad  diarrhea  for  a  week,  movements  very  watery  with 
mucus  and  some  blood.  Has  lost  much  weight  recently.  Chief  complaint  is  dyspnea, 
abdominal  soreness,  and  waterj'  stools. 

Lung:  over  right  apex  restricted  expansion,  increased  voice  sounds,  sonorous  rales  and 
prolonged  expiration.    Percussion  note  impaired  anteriorly  and  posteriorly. 

Abdomen:  slightly  distended;  complains  of  soreness  over  appendix  and  is  slightly  tender 
here.  Liver  not  palpable  below  costal  margin.  Spleen  not  palpable.  Left  inguinal  her- 
nia as  before.     Blood  Wassermann  reaction  is  negative.     Blood  Pressure  1x5-85. 

December  30.     Discharged  in  good  condition.     Diagnosis:  Chronic  endocarditis. 

January  17,  1916.  Readmitted  to  Dr.  Piersol's  Service,  complaining  of  vertigo,  dys- 
pnea, diarrhea,  and  vomiting.  Is  somewhat  emaciated.  Liver  extends  5  cm.  below  costal 
margin,  and  a  mass  is  palpable  below  the  costal  margin  in  the  left  midclavicular  line. 

January  24.     Test  meal:  Amount  removed  by  stomach  tube  100  cc. 

Microscopic: 
Free  HCl  negative  RBC  few 

Lactic  acid  positive  WBC  occasional 

Total  acids  43  Tumor  cells  negative 

Free  HCl  and  acid  salts  40  Oppler  Boas  Bac.  negative 

Combined  HCl  3  SarcinJe,  negative 

Parasites,  negative. 

January  27.  Nausea  improved.  Tran  ferred  to  Surgical  Service  (Dr.  .\shhurst)  for 
exploratorj-  operation. 

Patient  has  had  indigestion  for  2  years;  is  anemic;  vomits  occasionally  (about  twice 
weekly);  tjT^ical  retention  vomitus,  bloody;  the  abdomen  is  thin;  there  is  a  barely  palpable 
mass  in  the  epigastrium.     Diagnosis  (Dr.  Ashhurst) :  pyloric  stenosis. 

Januarj'  28.  Operation  (Dr.  Ashhurst),  Ether.  A  large  mass,  e\idently  malignant, 
was  found  in  body  of  the  stomach,  not  invol\-ing  pylorus  or  cardia,  but  extending  from 
greater  to  lesser  curvature  on  both  anterior  and  posterior  walls,  and  almost  completely  ob- 
structing its  lumen.  There  were  numerous  enlarged  rather  soft  lymphnodes  in  the  gastro- 
colic omentum;   fewer  and  smaller  lymphnodes  in   the  gastrohepatic   omentum.     The 


PROGNOSIS   AFTER   GASTRO-JEJUNOSTOMY  27I 

Stomach  was  not  fixed,  but  the  tumor  was  considered  inoperable  on  account  of  its  exten- 
sion so  far  toward  the  fundus  of  the  stomach,  and  on  account  of  the  patient's  weakness. 
No  metastases  were  found  in  the  liver.  The  gall-bladder  was  normal.  With  great  diffi- 
culty enough  of  the  posterior  wall  toward  the  fundus  of  the  stomach  was  exposed  through 
the  transverse  meso-colon  to  render  a  gastro-jejunostomy  possible;  the  anatomotic  opening 
was  less  than  5  cm.  in  length.     After  operation  enteroclysis  was  given. 

January  29.  Water  by  mouth.  Vomited  a  little  blood  while  coming  out  of  ether. 
No  unfavorable  symptom  since. 

February  i.    Liquid  diet. 

February  4.     Semi-soft  diet. 

February  12.     Sitting  up.     Feels  very  well.     Soft  and  extra  diet. 

February  16.     Walking  around  ward. 

February  19.     Went  home  in  good  condition. 

September  15.  Readmitted  to  Dr.  Ashhurst's  Service.  Has  been  in  perfect  health 
since  operation.  For  the  last  5  months  has  worked  as  farmer  (plov\ing,  hoeing,  harrowing, 
digging,  etc.,  as  usual),  with  no  disability  and  never  a  symptom  from  his  stomach. 

Returns  today  for  abdominal  pain  and  constipation  of  3  days  duration.  Has  had  a 
bowel  movement  every  day.  Abdomen:  A  firm  epigastric  mass  mo\-ing  in  respiration, 
extending  almost  to  umbilicus.  Irreducible  (incarcerated)  left  inguinal  hernia.  Diagno- 
sis, epiplocele. 

Operation  (Eucain  i  percent.)  by  Dr.  Ashhurst.  Nodules  of  metastatic  carcinoma  found  in 
an  otherwise  empty  hernial  sac.  Omentum  perhaps  spontaneously  reduced.  Much  yellow 
(not  bloody)  ascitic  fluid  drained  from  internal  ring  before  closing  wound.  Many  hard 
nodules  felt  in  omentum  by  finger  passed  through  internal  ring.     Sac  not  removed. 

September  22.     Uneventful  recovery.     No  vomiting.     Appetite  excellent. 

September  23.  X-Rays  show  tumor  obstructing  most  of  stomach,  with  only  pencil 
sized  channel  through  to  pylorus.     Stomach  empties  in  normal  time. 

September  29.     Went  home  in  good  condition.     Weight  138  pounds  with  clothes. 

November  4.  Readmitted  to  Medical  Ward,  Dr.  Robertson's  Service.  Chief  com- 
plaint: weakness  and  nervousness.  Ankles  began  to  swell  last  week,  and  began  to  get 
puffy  about  the  eyes.  Some  dypsnea,  frequency  of  urination,  and  gradually  increasing 
distention  of  abdomen. 

November  8.  Parancentesis  abdominis:  2140  cc.  of  clear  amber  fluid  withdrawn. 
Paracentesis  of  chest:  90  cc.  of  similar  fluid. 

December  8.  Paracentesis  abdominis  repeated:  1097  cc.  of  similar  fluid  withdrawn. 
Dyspnea  relieved. 

December  18.     Paracentesis  of  right  chest:  3600  cc.  of  similar  fluid  withdrawn. 

December  20.  Patient  allowed  to  go  home  unimproved.  Death  occurred  in  the 
following  February. 

The  average  duration  of  life  after  gastro-jejunostomy  for  malignant 
pyloric  obstruction  is  almost  certainly  longer  than  when  no  operation 
has  been  done;  but  so  far  as  we  have  been  able  to  ascertain,  the  details 
thus  far  have  been  published  in  too  few  cases  for  very  positive  con- 
clusions to  be  drawn.  Moynihan  traced  26  out  of  30  patients  who 
recovered  after  gastro-jejunostomy  for  cancer;  six  patients  were  still 
alive,  one  after  thirteen  months,  and  five  less  than  twelve  months 
since  the  operation.  Of  the  20  patients  who  had  died,  the  shortest 
duration  of  life  after  operation  was  fourteen  weeks;  wliile  two  patients 
had  Hved  more  than  two  years.     In  Kronlein's  patients  who  recovered 


272  CARCINOMA    OF   THE    STOMACH 

from  gastro-jejunostomy  and  were  traced  (54  in  number)  the  average 
duration  of  life  after  operation  was  193  days  (over  six  months),  and 
in  Mikulicz's  patients  it  was  6.4  months — or  in  each  series  about  3 
months  longer  than  if  no  operation  had  been  employed.  Moynihan, 
however,  notes  that  if  in  this  reckoning  the  immediately  fatal  cases 
are  included,  the  average  duration  of  life  is  slightly  less  than  if  no  oper- 
ation had  been  employed.  However,  the  statistics  of  Mikulicz  were 
compiled  in  1901,  and  those  of  Kronlein  in  1902;  and  it  is  but  reason- 
able to  suppose  that  since  that  time  some  improvement  ev'en  in  the 
results  of  gastro-jejunostomy  for  carcinoma  has  occurred. 

It  appears  from  these  statistics  that  in  the  hands  of  experienced 
abdominal  surgeons  the  immediate  mortality  from  gastro-jejunostomy 
in  patients  with  cancer  of  the  stomach  is  as  high  as,  and  in  some  in- 
stances even  higher  than  that  of  partial  gastrectomy  for  the  same 
disease.  But  even  if  these  statistics  represent  correctly  the  practice 
of  the  present,  which  is  a  little  doubtful,  it  is  not  probable  that  this 
difference  in  the  mortality  of  gastrectomy  and  gastro-jejunostomy  for 
cancer  is  due  to  any  inherent  qualities  of  the  respective  operations;  it 
seems  rather  attributable  to  the  fact  that  gastro-jejunostomy  has  been 
and  is  still  employed  in  patients  already  nearly  dead  from  starvation 
and  cachexia,  with  the  forlorn  hope  of  relieving  their  discomfort  during 
their  remaining  days  on  earth.  On  the  other  hand,  the  majority  of 
surgeons  have  been  fearful  of  employing  so  extensive  an  operation  as 
even  partial  gastrectomy  in  any  but  carefully  selected  patients.  We 
believe  that,  other  things  being  equal,  gastrectomj'  is  the  more  serious 
operation  of  the  two;  and  were  it  to  be  used  as  indiscriminately  as 
gastro-jejunostomy  has  been,  the  relative  mortality  rates  would 
appear  in  true  proportion.  Oversight  of  this  fact  seems  to  give  some 
basis  for  the  enthusiasm  with  which  Robson  and  Moynihan  suggest  the 
employment  of  gastrectomy  as  a  palliative  operation  even  in  cases 
where  it  is  manifestly  impossible  to  remove  the  entire  disease.  They 
speak  as  follows  of  the  results  of  gastro-jejunostomy  in  cases  of  pyloric 
obstruction  from  cancer:  "There  can  be  no  doubt  that  in  such  cases 
gastro-enterostomy  is  productive  of  the  most  remarkable  benefit  to 
the  health  and  well-being  of  the  patient.  The  weight  increases,  the 
appetite  and  the  power  of  gratifying  it  return,  and  vomiting,  often 
the  most  distressing  and  unceasing  symptom,  stops  at  once.  But 
there  can  also  be  no  doubt  that  in  some  instances,  when  the  growth 
does  not  actually  obstruct  by  its  bulk  the  onward  passage  of  food, 
a  decided  benefit  results  from  the  operation."  But  they  say  later, 
"  The  question  may  arise  as  to  whether  gastrectomy  should  not  be  per- 


PROGNOSIS   AFTER   JEJUNOSTOMY  273 

formed  deliberately  as  a  palliative  operation  in  cases  where  an  early- 
secondary  deposit  can  be  seen  in  the  liver,  or  inaccessible  or  irremov- 
able glands  be  found  in  the  pancreas,  or  along  the  aorta  and  vena 
cava.  If  we  take  into  account  the  following  advantages  of  gastrec- 
tomy as  compared  with  gastro-enterostomy — that  in  the  most  compe- 
tent hands  its  mortality  is  not  greater,  but  is  even  less,  than  the  mor- 
tality of  gastro-enterostomy;  that  a  prolongation  of  life  for  ten  months 
longer  than  the  period  given  by  gastro-enterostomy  is  the  rule;  that 
the  comfort,  the  general  health,  appetite,  and  well-being  of  the  patient 
are  all  emphatically  better;  and,  finally,  that  the  patient  has  always 
a  chance,  even  though  it  is  of  the  slenderest,  of  a  complete  recovery 
from  his  disease — if  we  take  all  these  into  our  consideration,  there  can 
be  no  doubt  that  the  operation  of  choice  will  always  be  gastrectomy." 
And  W.  J.  Mayo  (1914)  writes  that  "patients  subjected  to  the  removal 
of  the  visible  growth  in  the  stomach,  even  if  all  the  glands  cannot  be 
removed  will  get  a  year  or  more  on  the  average  of  a  very  comfortable 
existence  cheered  by  the  knowledge  that  there  is  a  possibility  of 
cure,  since,  in  some  cases,  irremovable  glandular  hyperplasia  is  the 
result  of  infection  rather  than  metastasis."  Nor  should  the  remark- 
able results  achieved  by  Temoin  be  overlooked:  this  surgeon  makes  a 
practice  of  removing  the  stomach  and  leaving  behind  all  enlarged 
glands — wiping  the  stomach  away  from  its  omental  attachments  by 
dry  gauze  dissection.  In  spite  of  this  partiality  of  these  experienced 
surgeons,  it  seems  to  us  that  gastrectomy  is  best  reserved  for  those  cases 
in  which  it  seems  likely  that  it  will  be  a  curative  operation.  Surely 
if  employed  when  secondary  deposits  exist  in  the  liver,  or  where  there 
are  inaccessible  or  irremovable,  but  nevertheless  surely  carcinoma- 
tous lymph  nodes — surely  in  such  cases  there  can  be  not  even  the 
slenderest  chance  of  a  complete  recovery  from  the  disease  after 
gastrectomy. 

Finally,  it  is  of  interest  in  this  connection  to  recall  the  researches 
of  Katzenstein  (1906),  as  the  result  of  which  he  suggested  that  the 
arrest  of  carcinomatous  growths  sometimes  observed  after  gastro- 
jejunostomy might  be  due  to  the  local  action  of  the  trypsin  of  the 
pancreatic  juice,  freely  admitted  to  the  stomach  after  the  usual  lateral 
anastomosis  employed  in  this  operation. 

Prognosis  after  Gastrostomy  and  Jejunostomy. — Still  other  pallia- 
tive operations  may  be  employed:  gastrostomy  in  patients  with 
carcinoma  of  the  cardiac  orifice,  and  jejunostomy  where  the  pylorus  is 
obstructed  and  the  stomach  is  too  extensively  diseased  for  the  perform- 
ance of  gastro-jejunostomy. 

18 


2  74 


CARCINOMA    OF    THE    STOMACH 


The  following  tables  show  the  mortality  in  several  series  of  cases 
of  jejmwstomy: 

Jejunostomy  for  Benign  Diseases  of  the  Stomach 


Operator 


No.  of 
operations 


Deaths 


Mortality 
per  cent. 


Berard  (1912) 

V.  Eiselsberg  (1914)  ^ 

Haudek  (1914) 

Remijnsee  (rgiz). . . 
Simon  (1913) 


3 

24 

6 

10 

13 


o 

12 

3 

I 
6 


0.0 
50-0 
50.0 
10. o 
46.0 


Jejunostomy  por  Malignant  Diseases  of  the  Stomach 


Operator 


No.  of       ,      T^     ,,  Mortality 

I      Deaths 
operations  per  cent. 


Altschul  (1913) S 

Berard  (1912) 7 

Hoffman  (191 1) 10 

Kiittner  (1911) 21 

Remijnsee  (191 2).  23 

Spencer  (1910) 5 


80.0 

8S.7 
80.0 
3O.0 

340 
80.0 


It  should  be  noted,  however,  that  the  figures  cited  above  do  not 
refer  in  all  instances  to  the  immediate  (operative)  mortahty,  but  include 
also  deaths  following  within  a  few  weeks  or  months  of  the  operation. 
But  the  operation  of  jejunostomy  per  se  and  quite  apart  from  the 
patient's  general  condition,  has  a  distinct  mortality  of  its  own,  evi- 
denced by  the  fact  that  death  in  not  a  few  instances  has  been  due  to 
intestinal  obstruction  from  occlusion  of  the  afferent  jejunal  loop  by 
kinking,  rotation,  strangulation  over  it  of  other  coils  of  intestine,  etc. 

Duodenostomy  (above  the  bile  papilla)  has  been  employed  suc- 
cessfully by  Hartmann,  and  he  advocates  it  as  in  every  way  superior 
to  jejunostomy.     We  have  had  no  experience  with  it. 

It  is  our  opinion  that  such  palliative  operations  as  these  are  very 
rarely  indicated.  It  is  very  unusual,  as  Dawson  reminds  us,  for  thirst  to 
be  an  annoying  s^onptom  of  carcinoma  of  the  esophagus  or  of  the  cardiac 
orifice  of  the  stomach;  and  we  consider  his  strong  condemnation  of  such 
meddlesome  surgery  fully  justified  by  the  trend  of  thought  today.  So 
long  as  patients  with  inoperable  internal  carcinoma  arc  not  starving 
to  death,  it  is  the  part  of  wisdom  to  refrain  from  palliative  and  useless 
operations. 


TREATMENT  275 

Treatment. — Having  pointed  out  in  the  section  on  Prognosis,  the 
expectation  of  life  and  the  hope  of  radical  cure  which  operative  treat- 
ment offers  to  patients  with  carcinoma  of  the  stomach,  it  next  becomes 
necessary  to  decide  upon  the  special  type  of  operation  to  be  adopted 
in  specific  cases  of  the  disease. 

The  terminology  of  gastric  surgery  is  not  entirely  uniform  through- 
out the  surgical  world.  The  terms  as  used  in  this  volume  are  defined 
in  the  chapter  on  the  Technique  of  Operations  on  the  Stomach  (Chap- 
ter XIV),  and  to  that  the  reader  is  referred  for  detailed  descriptions. 

Total  gastrectomy  will  very  rarely  be  advisable  Such  extensive 
invasion  of  the  gastric  wall  as  to  make  this  operation  requisite  will 
usually  be  found  to  be  accompanied  by  so  many  perigastric  adhesions 
or  by  such  obvious  metastases,  as  to  render  useless  any  but  a  palliative 
operation.  Though  successful  in  a  sufficiently  large  number  of  cases 
to  remove  the  procedure  from  the  realm  of  mere  surgical  experiment, 
it  is  not  an  operation  which  any  surgeon  should  feel  himself  competent 
to  undertake,  save  one  who  has  been  thoroughly  trained  in  gastro- 
intestinal surgery.  Trinkler  (191 1)  collected  26  cases  with  9  deaths 
(34.6  per  cent.). 

Subtotal  gastrectomy  (Fig.  1 1 2)  is  more  difficult  than  partial  gastrec- 
tomy only  where  adhesions  abound.  If  there  are  extensive  adhesions  to 
the  pancreas,  any  form  of  gastrectomy  must  usually  be  inadvisable. 
Although  in  a  few  cases  portions  of  the  pancreas  have  been  excised 
in  one  mass  with  the  stomach,  yet  the  danger  from  infection,  and  from 
the  digestive  action  of  the  pancreatic  juice  is  so  great,  that  the  surgeon 
is  rarely  justified  in  exposing  his  patient  to  the  greater  risk,  especially 
as  freedom  from  recurrence  in  these  cases  is  not  to  be  anticipated. 
The  raw  surface  of  the  pancreas  usually  must  be  covered  in  with  gauze 
packs,  and  the  patient's  convalescence  is  thus  much  more  delayed 
than  when  the  abdominal  incision  can  be  completely  closed.  Yet 
Childe  successfully  excised  a  layer  of  pancreatic  tissue  in  one  piece 
with  the  stomach  and  the  transverse  colon,  and  Sauve  has  published 
(1908)  a  paper  advocating  partial  pancreatectomy  when  necessary. 

Excision  of  the  transverse  colon  en  masse  with  the  cancerous 
stomach  appears  to  have  been  employed  at  least  in  39  cases,  with  26 
recoveries  and  13  deaths;  the  mortality  (33.9  per  cent.)  is  thus  con- 
siderably less  than  might  have  been  expected  from  so  extensive  an 
operation.  Leriche  (1906)  collected  31  cases,  and  at  least  8  additional 
cases  have  been  recorded  during  the  last  decade.  It  is  an  operation 
which  is  logically  correct,  when  the  transverse  colon  is  itself  invaded, 
but  not  to  such  an  extent  as  to  prevent  entire  removal  of  the  malignant 


276  CARCINOMA    OF    THE    STOMACH 

growth;  and  even  in  cases  where  the  blood  supply  of  the  colon  is 
jeopardized  by  the  radical  removal  of  the  gastric  disease  (as  in  Childe's 
patient,  referred  to  above,  and  in  Krause's  patient),  even  though  the 
colon  be  not  itself  invaded  by  carcinoma,  it  is  better  successfully  to 
remove  an  organ  whose  blood  supply  is  destroyed,  than  to  expose  the 
patient  to  almost  certain  death  from  gangrene  of  the  colon.  In  one 
patient  under  the  care  of  the  junior  author  at  the  Episcopal  Hospital, 
it  was  found  after  partial  gastrectomy  for  a  large  pre-pyloric  tumor 
(aferwards  proved  to  be  inflammatory)  that  the  blood  supply  of  the 
tranverse  colon  had  been  injured  in  detaching  the  adherent  posterior 
gastric  wall;  the  transverse  colon  was  therefore  resected,  an  end-to-end 
anastomosis  being  done.  Recovery  was  uneventful  (Figs.  30,  31).  In 
a  few  instances  (Massmann,  Ross,  and  others) ,  the  middle  colic  artery  has 
been  unwittingly  ligated  in  doing  a  gastrectomy,  and  the  patients  have 
died  from  peritonitis  due  to  the  ensuing  gangrene  of  the  transverse 
colon. 

Partial  gastrectomy  is  the  operation  of  choice  for  the  radical  cure 
of  gastric  carcinoma.  As  already  remarked  the  differences  between 
it  and  subtotal  gastrectomy  are  slight,  in  regard  to  difficulty  of 
performance,  immediate  mortality,  or  operative  technique.  Sub- 
total gastrectomy  is  necessitated  by  a  more  extensive  invasion  of  the 
neoplasm  toward  the  fundus  and  along  the  greater  curvature.  The 
question  of  most  interest  in  this  connection,  in  regard  to  partial  gas- 
trectomy, is  the  method  to  be  adopted  for  restoring  the  continuity  of 
the  gastro-intestinal  canal.  These  methods  are  Billroth's  first  method; 
Billroth's  second  method;  Kocher's  method;  and  posterior  trans- 
mesocolic  gastro-jejunostomy — which  latter  procedure  includes  sev- 
eral subvarieties,  as  the  long  loop  method  (with  or  without  entero- 
anastomosis) ,  the  no  loop  method,  the  Y-method,  Polya's  method, 
etc.  Full  descriptions  of  these  various  methods  w'ill  be  found  in 
Chapter  XIV. 

Billroth's  first  -method  is  nearly  universally  condemned.  Accord- 
ing to  Paterson  leakage  at  the  "fatal  angle"  occurred  in  23  percent, 
of  the  cases  he  collected.  Kocher  quotes  Guinard's  collective  statis- 
tics, of  148  gastrectomies  b_v  Billroth  I,  with  a  mortality  of  35.3  per 
cent.  After  mere  pylorectomy,  however,  the  mortality  is  lower  than 
this  (p.  278). 

Billroth's  second  vielhod  (anterior  gastro-jejunostomy),  though 
inferior  in  our  judgment  to  an  operation  completed  by  a  posterior 
trans-mesocolic  gastro-jejunostomy,  is  more  widely  applicable  than 
the  latter,  in  cases  of  subtotal  gastrectomy,  when  the  cardiac  pouch 
is  small.     Unless  it  is  contra-indicated,   our  preference  is  for   the 


CHOICE    OF    OPERATION  277 

restoration  of  the  gastro-intestinal  canal  by  posterior  trans-meso- 
colic  gastro-jejunostomy,  by  the  "no-loop"  method  or  by  Polya's 
method.  Difficulty  of  performance,  as  after  subtotal  gastrectomy, 
is  the  chief,  indeed  almost  the  only  valid,  contra-indication. 

Kochcr's  melhod  was  of  course  strenuously  supported  by  its  author. 
He  quoted  Guinard's  collective  statistics  of  64  operations  by  this 
method,  with  a  mortahty  of  15.6  per  cent.  In  the  hands  of  Kocher 
and  his  associates  (1907)  this  operation  had  been  employed  92  times, 
with  14  deaths,  a  general  mortality  of  15.2  per  cent.  (12  deaths  among 
the  first  71  operations,  or  a  mortality  of  16.9  per  cent.;  and  2  deaths 
among  the  last  21  operations,  a  mortality  of  only  9.5  per  cent.). 
Kocher  further  calls  attention  to  the  fact  that  all  but  three  of  the 
patients  permanently  cured  were  operated  on  by  this  method;  of 
these  three,  one  patient  was  operated  on  by  Billroth's  first  method; 
and  in  two  patients  the  operation  was  circular  (cylindrical)  gastrec- 
tomy. 

Folya's  method,  in  which  a  lateral  anastomosis  (transmesocolic) 
is  made  between  the  upper  jejunum  and  the  open  stump  of  the  stom- 
ach, is  especially  valuable  after  subtotal  gastrectomy,  where  the 
pouch  of  stomach  which  remains  is  very  small  or  difficult  of  access. 

The  operations  of  cylindrical  gastrectomy  and  of  gastric  resection 
are  very  rarely  indicated  in  cases  of  malignant  disease.  In  carcinoma 
involving  only  the  median  portion  of  the  stomach,  the  former  may 
sometimes  be  available,  but  the  rule  enunciated  by  Leriche  (1907), 
himself  one  of  the  chief  advocates  of  cylindrical  gastrectomy,  should 
be  strictly  enforced — namely,  that  cylindrical  gastrectomy  is  ab- 
solutely contraindicated  if  there  are  enlarged  glands  in  the  gastro- 
hepatic  omentum;  since  under  these  conditions  it  is  imperative  for  the 
surgeon  to  remove  the  entire  lesser  curvature.  Reidel  (1909)  reports 
a  series  of  23  cylindrical  gastrectomies  for  benign  disease,  with  a  mor- 
tahty of  26  per  cent.  In  cases  of  carcinoma  the  death  rate  probably 
is  higher. 

Enderlen's  experience,  reported  by  Faulhaber  and  Rewitz  (1914), 
probably  is  exceptional:  in  his  service  there  have  been  done  26  cyl- 
indrical gastrectomies,  with  only  one  death,  due  to  leakage  at  the 
suture  line. 

Gastric  resection  is  suitable  only  for  tumors  confined  to  the  anterior 
or  the  posterior  wall  of  the  stomach,  and  involving  neither  curvature; 
or  for  those  confined  to  the  greater  curvature  alone,  near  the  fundus. 
How  extremely  rare  such  growths  are,  is  recognized  by  all;  and  even 
should  it  seem  possible  to  adopt  this  operation,  the  execution  of  a 


278  CARCINOMA    OF    THE    STOIVL\CH 

typical  partial  or  subtotal  gastrectomy  would  not  only  prove  easier 
in  most  cases,  but  would  offer  a  greater  chance  of  ultimate  cure. 

The  following  figures  from  the  Mayo  Clinic  have  been  published 
by  C.  H.  Mayo  (1919). 

Operation  No.               Mortality    per  cent. 

Billroth  1 19                                5.0 

Billroth  II 3S9  12.5 

Kocher 7  14.2 

Cylindrical 28  14.2 

Posterior  Polya 115  14.7 

Anterior  Polya 120  13 .3 

Resections 12  250 

Gastrostomy  is  appUcable  only  to  cancer  of  the  cardiac  orifice 
or  of  the  esophagus.  We  think  it  should  seldom  or  never  be  employed 
in  the  case  of  patients  who  can  still  swallow  liquids. 

Jejunostomy  or  Duodenostomy  may  occasionally  be  adopted 
in  cases  of  diffuse  infiltration  of  the  gastric  walls  not  admitting  of 
gastro-jejunostomy.  In  employing  either  gastrostomy  or  jejunostomy 
the  precarious  state  of  the  patient  must  be  kept  in  mind;  it  is  best  for 
the  surgeon  to  know  before  beginning  the  operatioii  just  what  he  in- 
tends to  do,  and  then  to  do  it  without  any  unnecessary  intra-ab- 
dominal explorations.  By  heeding  this  advice,  and  by  adopting  these 
operations  as  soon  as  a  diagnosis  is  made,  instead  of  waiting  until  the 
patient  has  one  foot  already  in  the  grave,  the  surgeon  may  expect  his 
immediate  mortaHty  to  be  almost  nil,  and  his  patients  really  to  derive 
some  benefit  from  the  operation. 


o 


CHAPTER  XII 

CARCINOMA  OF  THE  DUODENUM;  SARCOMA  AND  ENDO- 
THELIOMA OF  THE  STOMACH  AND  DUODENUM 

Carcinoma  of  the  Duodenum  is  rare.  Deaver  and  Ravdin  (1920) 
collected  records  of  151,201  autopsies,  among  which  carcinoma  of  the 
duodenum  was  found  50  times,  or  in  0.033  P^r  cent,  of  cases.  G.  Jeffer- 
son (1916)  noted  that  of  4177  cases  of  intestinal  carcinoma,  only  130  or 
3.1  per  cent.,  were  situated  in  the  small  bowel;  or  in  other  words,  that 
96.9  per  cent,  of  the  cases  occurred  in  the  colon  or  rectum.  But  among 
132  cases  of  carcinoma  of  the  small  intestine  in  which  the  location  of  the 
tumor  was  definitely  stated,  63  or  nearly  48  per  cent,  were  in  the  duo- 
denum, and  69  in  the  jejuno-ileum  (Deaver  and  Ravdin) ;  considering 
the  relative  length  of  the  duodenum  to  the  remainder  of  the  small 
bowel,  it  is  seen  that  there  is  a  very  striking  predilection  for  the  former 
to  be  affected,  especially  when  it  is  borne  in  mind  that  these  figures 
do  not  include  carcinoma  of  the  papilla  of  Vater. 

Duodenal  carcinoma  usually  is  described  according  to  the  relation 
it  bears  to  the  orifice  of  the  bile  duct  in  the  duodenum,  as  supra-ampul- 
lary  (para-pyloric) ,  juxta-ampullary  (peri-ampullary) ,  and  infra- 
ampullary  (juxta-jejunal) .  Of  these  forms  the  juxta-ampullary  is  the 
most  frequent;  it  is  not  considered  in  this  place,  but  in  connection  with 
obstruction  of  the  bile-ducts  (p.  506).  Among  158  cases  of  duodenal 
carcinoma  collected  by  Deaver  and  Ravdin  (1920),  35  (22.15  per  cent.) 
involved  the  first  part;  104  (65.82  per  cent.)  were  in  the  second  or 
descending  portion;  and  19  (12.02  per  cent.)  in  the  third  (transverse) 
portion.  Forgue  and  Chauvin  (1914)  succeeded  in  collecting  45  cases 
of  (non-ampullary)  carcinoma  of  the  duodenum,  in  29  of  which  the 
site  of  the  growth  was  given:  17  were  supra-ampullary,  11  infra- 
ampuUary,  and  in  i  case  the  involvement  was  diffuse. 

Little  is  known  of  the  etiology  of  duodenal  carcinoma.  Jefferson 
(1916)  found  records  only  of  30  cases  of  carcinoma  of  the  duodenum 
which  certainly  followed  ulcer,  and  even  in  some  of  these  the  existence 
of  a  preceding  ulcer  is  assumed  rather  than  proved.  Houdard  (1913), 
according  to  Jefferson,  thinks  the  rarity  of  carcinoma  following  ulcer 
of  the  duodenum  is  due  to  the  rare  occurrence  of  callous  ulcers  in  this 
situation ;  this  in  turn  being  due  to  the  absence  of  the  thick  submucosa 
which  in  the  stomach  forms  such  a  favorable  site  for  the  development 
of  inflammatory  thickening  around  the  base  of  the  ulcer  (Plate  I). 

279 


28o  CARCINOMA    OF    THE   DUODENUM 

Several  cases  are  quoted  by  Jefferson  (Sherren,  Mayo,  Bland  Sutton) 
where  an  ulcer  of  the  duodenum  has  extended  into  the  stomach  and  has 
become  malignant  only  in  its  gastric  portion. 

Most  duodenal  carcinomata  are  of  the  cylindrical  celled  variety 
(adenocarcinoma).  The  growth,  especially  when  adenocarcinoma,  is 
apt  to  constrict  the  intestine,  and  symptoms  of  obstruction  are  there- 
fore prominent.  When  viewed  from  outside  the  gut,  the  appearance 
is  as  if  a  "string  had  been  tied  tightly  around  the  bowel"  (Fenwick). 
If  above  the  bile  papilla  the  sj-mptoms  of  pyloric  obstruction  are  so 
closely  simulated  as  to  make  a  difJerential  diagnosis  impossible.  When 
upon,  or  in  the  immediate  neighborhood  of  the  bile-papilla,  chronic 
jaundice  is  present,  and  differentiation  from  other  causes  of  biUary 
obstruction  becomes  important  (p.  506).  An  accompanying  dilatation 
of  the  stomach,  usually  absent  in  affections  confined  to  the  biliary  and 
pancreatic  tracts,  may  be  an  important  differential  sign.  Below  the 
orifice  of  the  common  bile-duct,  obstruction  of  the  duodenum  is  less 
difficult  to  recognize;  the  nearly  constant  presence  of  bile  in  the  vomitus 
is  a  most  important  symptom.  If  this  were  due  to  a  gastro-biliary 
fistula,  instead  of  to  regurgitation  of  bile  from  the  duodenum,  the 
vomitus  would  not  be  found  to  contain  the  pancreatic  ferments  as  well 
as  bile.     Finally,  in  no  case  should  fluoroscopic  examination  be  omitted. 

Treatment  should  be  by  operative  means,  which  often  are  requisite 
for  a  correct  diagnosis.  Unfortunately  in  most  cases  only  a  palhative 
operation  (gastro-jejunostomy)  can  be  performed.  Syme  (1904) 
resected  three  inches  and  a  half  (9  cm.)  of  the  third  portion  of  the 
duodenum  for  an  annular  carcinoma,  restoring  the  intestinal  canal  by 
end-to-end  anastomosis  of  the  duodenum  by  suture;  his  patient  re- 
covered and  was  in  good  health  three  months  later.  Forgue  and 
Chauvin  (1914)  mention  3  other  radical  operations  in  addition  to  that 
recorded  by  Syme,  with  2  successes. 

In  a  patient  at  the  Lankenau  Hospital,  the  senior  author  operated 
for  symptoms  of  4  mos.  duration,  especially  vomiting  and  epigastric 
pain;  he  excised  from  the  juxta-pyloric  portion  of  the  duodenum  a 
small  nut-sized  tumor  which  was  found  on  microscopical  examination 
to  be  carcinomatous;  the  growth  was  of  the  adenomatous  type,  seem- 
ingly derived  from  the  pancreas,  of  which  tissue  there  were  some  areas 
in  the  section.  The  patient  was  in  good  health  one  year  after  the 
operation,  but  has  not  been  traced  subsequently. 

In  a  second  patient  with  carcinoma  of  the  duodenum,  under  his 
care  in  the  University  Hospital  (1919),  whose  history  he  has  reported 
(1920)  in  association  with  Dr.  I.  S.  Ravdin,  operation  was  undertaken 


SARCOMA   OF   THE   DUODENUM  28 1 

upon  a  diagnosis  of  caicinoma  of  the  stomach:  a  fixed  mass  was  found 
arising  from  the  posterior  inner  wall  of  the  duodenum,  below  the  papilla 
of  Vater,  near  the  termination  of  the  second  portion.  After  mobiliza- 
tion of  the  duodenum  it  was  found  that  the  ulcerating  mass  had  invaded 
the  pancreas  and  become  inoperable.  A  posterior  gastro-jejunostomy 
was  done  but  the  patient  died  suddenly  of  acute  dilatation  of  the  heart 
48  hours  after  operation. 

Sarcoma  of  the  Duodenum. — Fenwick  (1902)  referred  to  21  cases. 
Obstruction  is  rare,  the  tumor  being  rather  soft  and  vascular  than 
constricting.  Fatal  hemorrhage  has  been  noted  (Rolleston).  Angier 
and  Feivez  (1912)  report  a  case  in  a  child  aged  four  years  and  a  half; 
death  occurred  soon  after  operation. 

Sarcoma  of  the  stomach  has  been  considered  a  rare  disease ;  but  Fen- 
wick (1902)  observed  two  examples  of  round  celled  sarcoma  among 
"twenty-three  consecutive  autopsies  upon  persons  who  had  died  from 
primary  neoplasms  of  the  stomach,"  and  Venturelli  (1915)  has  collected 
172  cases  of  gastric  sarcoma.  Some  of  the  cases  recorded  as  such  prob- 
ably are  not  true  sarcomata.  Hosch  (1907)  found  among  13,387  autop- 
sies, recorded  in  the  University  of  Basel,  that  there  were  168  instances 
of  sarcoma;  and  that  6  of  these  (3.5  per  cent,  of  the  sarcomata)  were 
primary  in  the  stomach.  The  metastatic  is  much  less  rare  than  the 
primary  form. 

Yates  (1906)  found  from  a  study  of  the  literature  that  from  28  to  45 
per  cent,  of  the  reported  tumors  were  of  the  round  cell  variety,  from  3  2 
to  36  per  cent,  of  the  spindle  cell  form,  while  lymphosarcoma  con- 
stituted from  15  to  35  per  cent,  of  cases.  Mixed  tumors  are  frequent, 
among  those  encountered  being  the  myxomatous  and  the  angeiomatous; 
fibrosarcomata  and  myosarcomata  also  are  not  unusual.  Cysts  may 
form  from  hemorrhages  or  necrotic  processes  in  the  central  parts  of  the 
tumor.  Indeed  it  is  not  infrequently  impossible  even  for  a  skilled 
pathologist  to  determine  whether  such  a  tumor  is  a  myoma,  a  myxoma, 
an  angeioma,  or  a  true  sarcoma,  or  even  an  endothelioma;  and 
when  the  existence  of  a  mixed  form  is  indubitable,  it  may  be  impos- 
sible to  say  whether  the  angeioma,  the  myoma,  etc.,  was  the  primary 
growth  and  was  originally  benign,  or  whether  the  tumor  was  malignant 
(sarcomatous)  ab  initio.  This  uncertainty  was  noted  when  describmg 
benign  tumors  of  the  stomach,  and  is  merely  recalled  here  in  passing, 
since  any  discussion  of  moot  points  in  pathology  would  be  out  of  place 
in  a  work  of  this  kind. 

The  sarcomatous  growth  usually  commences  in  the  submucous 
tissues,  and  the  mucosa  may  remain  intact  for  a  considerable  time. 


282  SARCOMA   OF    THE    STOMACH 

The  tumor  frequently  attains  a  considerable  size,  and  may  project 
into  the  cavity  of  the  stomach  or  may  protrude  beneath  its  serous  coat, 
sometimes  invading  the  gastro-hepatic  or  the  gastro-coUc  omentum. 

Gastric  sarcoma  has  been  found,  according  to  Yates,  at  the  cardiac 
orifice  in  6  per  cent,  of  cases,  at  the  fundus  in  58  per  cent.,  at  the 
pylorus  in  only  36  per  cent,  (compared  to  60  per  cent,  of  carcinomata 
found  at  the  pylorus) ;  and  no  more  than  9  per  cent,  of  those  at  the 
pylorus  produced  obstruction.  About  one-third  of  the  tumors  were 
more  or  less  diffuse.  Yates  found  that  metastasis  was  noted  in  70 
per  cent,  of  the  round  cell  sarcomata  and  lympho-sarcomata,  and  in 
less  than  50  per  cent,  of  the  spindle  cell  variety.  The  kidneys  (in  28 
per  cent.) ;  the  liver,  ovaries,  pancreas,  adrenals  and  omentum  (each 
in  14  per  cent.) ;  and  the  lungs,  diaphragm,  pleuras,  esophagus,intestine, 
and  mesentery  (in  about  7  per  cent.),  are  the  organs  most  often  in- 
volved (Fenwick).  The  skin  presented  metastatic  nodules  in  about 
12  per  cent,  of  the  reported  cases.  Hosch  (1907)  calls  particular  atten- 
tion to  the  fact  that  whereas  sarcomata  in  general  (throughout  the 
body)  give  metastases  to  the  liver  in  40  per  cent,  of  cases,  those  which 
were  primary  in  the  stomach  produced  secondary  hepatic  growths  in 
only  one-tenth  of  the  recorded  cases. 

Symptoms. — The  s}Tnptoms  due  to  the  presence  of  a  malignant 
growth,  namely,  anemia,  emaciation,  etc.,  are  similar  to  those  en- 
countered in  patients  with  gastric  carcinoma;  but  pyloric  obstruction, 
which  is  usual  in  the  latter  disease,  is  seldom  seen  in  cases  of  sarcoma 
of  the  stomach;  and  a  history  of  long  standing  dyspepsia  is  also  rare. 
Tests  of  the  gastric  secretion  give  results  similar  to  those  obtained  in 
carcinoma.  Fenwick  lays  stress  upon  the  great  enlargement  (non-ma- 
lignant) of  the  spleen,  in  15  per  cent,  of  patients  with  sarcoma  of  the 
stomach;  this  enlargement,  when  present,  is  an  important  differential 
sign.  Perforation  is  said  to  be  more  frequent  (11  per  cent.)  than  in 
carcinoma  of  the  stomach.  Hemorrhage  is  characteristic  of  the  an- 
geiomatous  and  myomatous  forms.  Carcinoma  and  sarcoma  have 
been  found  associated  twice  in  the  stomach. 

Diagnosis  from  carcinoma  is  rarely  possible  before  operation, 
and  often  a  distinction  can  be  reached  only  by  microscopical  exami- 
nation. The  age  of  the  patient  is  an  unreliable  guide:  among  70  cases 
where  the  age  was  recorded,  Hosch  found  27  patients  under  40  years 
of  age,  26  over  50  years  of  age,  and  17  (the  greatest  number  in  any 
decade)  between  40  and  50  years.  The  very  marked  prostration 
of  strength,  the  excessive  anemia,  and  the  early  occurence  of  slight 
but  persistent  pyrexia,  all  speak  in  favor  of  sarcoma.     When   the 


Plate  I\' 


I    i 


Endothelioma  Springing  from  Pylorus.  Specimen  Removed  by  Partial  Gastrectomy. 
Above  can  be  seen  the  Pyloric  Portion  of  the  Stomach  with  its  Sectioned  Surfaces  and 
Pouting  Mucosa;  Between  them  the  Remains  of  the  Gastrohepatic  Omentum.  Below  is 
the  Tumor,  Springing  in  Three  Great  Masses  from  the  Greater  Curvature  Beneath  the 
Pylorus.  Female  46  Years.  Recovered,  and  in  Good  Health  One  Year  after  Operation. 
Path.  No.  12.776.     [.ankciuiii  Hospital. 

Face  p.  2X2 


ENDOTHELIOMA   OF   THE    STOMACH  283 

abdomen  is  opened,  one  would  be  inclined  to  diagnosticate  sarcoma 
from  the  existence  of  a  well  defined  tumor,  especially  if  of  rather  large 
size,  not  obstructing  the  pylorus,  softer  and  more  vascular  than  a 
a  carcinoma,  situated  on  one  of  the  gastric  walls  or  at  the  fundus, 
rather  than  along  the  lesser  curvature;  and  from  the  absence  of  peri- 
gastric adhesions. 

Prognosis. — Without  operation  the  average  duration  of  life  is 
"fifteen  to  eighteen  months  for  the  round  cell,  and  twenty-four  to 
thirty-two  months  for  the  spindle  cell  forms,  both  distinctly  longer 
than  carcinoma."     (Yates.) 

Treatment. — If  a  satisfactory  diagnosis  cannot  be  reached  within  a 
few  weeks,  exploratory  operation  should  be  urged.  Haggard  (,1920) 
has  collected  107  cases  in  which  operation  was  done — among  58  partial 
gastrectomies  there  were  1 5  deaths  (,25.8  per  cent.) ,  and  among  10  pallia- 
tive or  merely  exploratory  operations  there  were  8  deaths  (80  per  cent.) ; 
the  results  of  the  other  operations  are  not  recorded.  The  heavy 
mortality  \i\  cases  in  which  exploration  only  was  done,  no  doubt  is  to 
be  attributed  to  the  precarious  condition  of  the  patients.  More  an- 
cient series  of  operations,  however,  gave  a  higher  mortahty  for  radical 
operation:  thus  Zesas  (1913)  collected  40  radical  operations,  with  15 
deaths,  a  mortaUty  of  37.5  per  cent. 

The  prospect  for  permanent  cure  is  not  very  favorable:  in  12  cases 
referred  to  by  Frazier  (1914)  in  which  the  subsequent  history  is  known, 
I  survived  14  years,  2  for  2  years,  i  for  i  year,  i  had  recurrence  3 
years  after  operation,  and  8  were  reported  well  from  2  to  11  months 
after  operation.  Hesse's  patient  (191 2),  not  included  in  Frazier's 
statistics,  was  reported  living  and  well  7}^  years  after  operation. 

Endothelioma  of  the  Stomach. — Jorgensen  (191 1)  cites  5  cases  of 
this  nature,  and  a  few  have  been  reported  since.  Both  clinically  and 
microscopically  it  resembles  sarcoma.  We  have  references  to  6 
operations  for  endothelioma  of  the  stomach.  Morris  (1910)  did  gas- 
tro-jejunostomy  for  an  inoperable  tumor,  the  diagnosis  being  made  from 
a  section  removed  at  operation;  Stauder  (1908),  Maylard  and  Ander- 
son (1910),  Jorgensen  (1911),  Schiassi  (1912),  and  Sherrill  (1915)  did 
radical  operations;  4  of  the  patients  are  said  to  have  survived  the  re- 
section; Jorgensen's  patient  was  still  free  from  recurrence  10  months 
later;  Stauder's  patient  developed  symptoms  of  recurrence  4  months 
after  operation ;  and  the  late  history  in  the  other  patients  is  not  recorded. 

In  the  case  of  the  patient  whose  stomach  forms  the  subject  of 
Plate  IV,  partial  gastrectomy  was  successfully  done  by  the  senior 
author,  but  the  patient  cannot  be  traced. 


CHAPTER  XIII 

INJURIES  .OF  THE  DL\PHRAGM,  STOMACH  AND 
DUODENUM 

Of  the  various  injuries  to  be  considered  in  this  chapter,  the  ma- 
jority are  rare  occurrences  in  ci\il  hospitals.  The  nationality  of 
patients  has  also  a  considerable  influence  in  determining  the  relative 
frequency  with  which  stab-wounds  and  gunshot  wounds  are  encoun- 
tered, while  subcutaneous  ruptures  are  almost  exclusively  confined  to 
city  hospitals  with  large  accident  ser^^ces.  Stab-wounds  are  therefore 
more  frequent  in  southern  Europe,  and  among  Italian  laborers  in  this 
country,  than  in  other  portions  of  our  population;  while  gunshot 
wounds  are  rare  in  northern  cities,  except  from  negro  brawls,  compared 
to  their  incidence  in  the  southern  states,  where  the  experience  of  one 
surgeon  may  embrace  a  hundred  or  more  operations  for  such  injuries. 

I.  Injuries  of  the  Diaphragm. — These  are  of  interest  to  the  abdom- 
inal surgeon  because  of  the  frequency  of  abdominal  complications. 

(A)  Stab-wounds. — These  usually  result  from  penetration  of  one 
of  the  lower  (sixth  to  tenth)  intercostal  spaces  on  the  patient's  left. 
The  lung  is  rarely  injured,  but  the  dagger,  if  it  penetrates  the  dia- 
phragm, not  unfrequently  punctures  the  stomach,  the  colon,  or  the 
omentum.  Among  73  operations  for  wounds  of  the  diaphragm,  an- 
alyzed by  Suter,  there  was  injur\'  of  the  abdominal  contents  in  24 
cases,  or  33. S3  per  cent. 

The  symptoms  are  chiefly  those  of  shock  and  hemorrhage.  The 
omentum  frequently,  and  the  stomach  or  colon  occasionally,  protrudes 
in  the  thoracic  wound ;  this  is  of  course  pathognomonic  of  penetration 
of  the  abdominal  cavity.  The  physical  signs  closely  resemble  those  of 
diaphragmatic  hernia  (see  p.  239).  Operation  should  be  undertaken 
before  sufiicient  time  has  elapsed  for  evidences  of  peritonitis  to 
appear. 

The  prognosis  without  operation  is  very  bad.  Sorrentino  (1895) 
referred  to  33  cases  in  which  no  operation  was  done.  Of  these  patients, 
29  died,  a  mortahty  of  87.8  per  cent.  Among  the  29  deaths,  15 
occured  soon  after  the  injury,  giving  an  immediate  mortality  without 
operation  of  50  per  cent.;  the  other  14  patients  lived  for  months  or 
years,  and  then  died  from  conditions  which  prompt  operation  can  pre- 

284 


STAB-WOUNDS    OF   THE   DIAPHRAGM 


285 


vent.  The  causes  of  death  in  the  patients  who  died  soon  after  injury 
were  as  follows: 

Incarceration  of  abdominal  organs  in  wound  of  diaphragm 7  patients. 

Extravasation  of  gastric  contents  into  pleural  cavity 5  patients. 

Hemorrhage i  patient. 

Empyema 2  patients. 

Of  those  patients  who  survived  their  injuries  for  the  time  being,  every 
one  reported  died  later  from  incarceration  of  the  diaphragmatic  hernia. 
Although  these  figures  are  not  very  recent,  they  may  be  accepted  as  a 
fair  indication  of  what  the  outcome  of  these  cases  must  be  if  no  opera- 
tion be  employed,  as  the  non-operative  treatment  of  such  cases  has 
changed  little,  if  at  all,  since  these  statistics  were  collected. 

On  the  other  hand,  the  results  of  operation  are  very  encouraging. 
Lenormant  in  1903  collected  31  operations  for  wounds  of  the  dia- 
phragm, with  only  8  deaths,  a  mortality  of  25.8  per  cent.  Suter  in 
1905  analyzed  79  such  operations;  70  patients  recovered,  a  death  rate 
of  1 1.4  per  cent.  Of  the  9  fatal  cases,  only  2  were  unaccompanied  by 
injury  of  the  abdominal  viscera.  Salomon!  (1910)  studied  229  opera- 
tions for  stab  wounds  of  the  diaphragm:  only  46  patients  died,  a  mor- 
tality of  20  per  cent. 

Treatment. — It  being  decided  that  operation  is  indicated,  it  next 
becomes  necessary  to  determine  what  the  operation  shall  be;  whether 
thoracotomy,  laparotomy,  thoraco-laparotomy,  or  a  combined  opera- 
tion (an  operation  which  opens  both  pleural  and  peritoneal  cavities 
by  means  of  a  single  incision). 

Operations  for  Stab-wounds  of  the  Diaphragm  (Salomoni) 


Operation 


No.  of 
cases 

Recovered 

Died 

163 

148 

15 

39 

21 

18 

27 

14 

13 

229 

183 

46 

Mortality 
per  cent. 


Thoracotomy 

Laparotomy 

Thoraco-laparotomy      and      "combined 
operation" 

Total 


8.6 
46.0 

50.0 


The  much  higher  mortality  in  cases  treated  by  laparotomy  is  not 
due,  as  might  be  supposed  at  first  sight,  to  graver  injuries  than  in  the 
cases  of  patients  treated  by  thoracotomy.  Suter  (1905)  gave  the 
following  figures  for  24  operations  in  which  injuries  of  the  abdominal 
viscera  were  present: 


286  INJURIES    OF   DIAPHRAGM,    STOMACH   AND   DUODENOM 

Operations  for  Stab-wounds  of  the  Diaphragm  Complicated  by  Injuries  of  Abdomi- 
nal Viscera 


Operation 

Recovered        Died 
cases 

Mortality 
per  cent. 

Laparotomy 

Thoraco-laparotomy 

"  Combined  operation" 

9                    5                 4 

2                             I                         I 
I                             0                        I  J 
12                             II                            I 

50.00 
8.30 

J.  D.  S.  Davis  (1914)  reports  a  remarkable  series  of  four  operations 
for  recent  stab  wounds  of  the  diaphragm,  all  of  the  patients  recovering: 
in  three  the  diaphragm  was  repaired  by  thoracotomy  and  the  abdomen 
was  immediately  opened  for  exploration;  in  one  j)atient  no  abdominal 
lesion  was  found;  in  the  second  a  wound  of  the  stomach,  and  in  the 
third  one  of  the  colon  was  repaired.  The  details  of  operation  in  the 
fourth  case  are  not  recorded. 

The  technique  of  the  operation  is  essentially  the  same  as  that  for 
diaphragmatic  hernia,  which  has  already  been  described  (p.  242). 
By  laparotomy  it  is  usually  very  difficult,  if  not  impossible  (i)  to  reduce 
the  herniated  organs,  owing  to  the  negative  pressure  within  the  thorax; 
(2)  to  repair  the  wound  in  the  diaphragm;  (3)  to  suture  wounds  of  the 
cardia  or  the  fundus  of  the  stomach.  If  the  herniated  viscera  can  be 
reduced  from  within  the  abdomen,  pneumothorax  is  produced  by  this 
procedure  quite  as  surely  as  by  the  operation  of  thoracotomy.  By  the 
latter  operation  the  injured  viscera  can  be  quite  satisfactorily  repaired, 
as  well  as  the  wound  in  the  diaphragm ;  or  if  there  seem  good  reason  to 
believe  that  further  abdominal  injuries  exist,  inaccessible  to  treatment 
from  above,  the  abdomen  may  be  opened  subsequently  as  was  done  by 
Davis  in  the  cases  mentioned  above.  Pleural  infection  occurred,  ac- 
cording to  Suter,  in  less  than  10  per  cent,  of  the  whole  number  of 
operations. 

(B)  Gvinshot  wounds  of  the  diaphragm  have  no  interest  apart 
from  the  accompanying  visceral  injuries.  Yet  Robert  (1903)  reported 
the  case  of  a  patient  who  died  from  strangulated  diaphragmatic 
hernia  one  year  after  a  gunshot  perforation  of  the  diaphragm,  from 
which  he  had  recovered  without  operation;  and  a  similar  case  came 
under  the  notice  of  the  junior  author  at  the  Episcopal  Hospital  some 
years  ago:  Operation  was  done  by  another  surgeon  for  symptoms  of 
acute  intestinal  obstruction,  the  operation  being  abandoned  when  no 
cause  of  obstruction  could  be  found;  and  the  signilicance  of  the  history 


RUPTURE    OF    THE    DIAPHRAGM  287 

of  a  gunshot  wound  in  the  thorax  many  years  previously  was  not  appre- 
ciated until  at  autopsy  a  strangulated  diaphragmatic  hernia  was  found. 

(C)  Rupture  of  the  Diaphragm. — Subcutaneous  as  distinguished 
from  percutaneous  injuries  of  the  diaphragm  are  extremely  rare. 
Iselin  (1907)  advises,  and  we  believe  justly,  that  primary  laparotomy 
be  the  operation  of  choice  in  these  cases,  since  extensive  lesions  of  the 
abdominal  viscera  are  more  frequent  than  in  the  case  of  stab-wounds, 
and  hemorrhage  from  ruptured  blood-vessels  may  be  inaccessible  by 
the  thoracic  route.  If  it  be  difficult  to  reduce  the  herniated  organs, 
the  surgeon  may  create  a  pneumothorax  by  a  small  intercostal  incision, 
whereupon  reduction  will  be  easy.  After  the  more  serious  lesions 
have  been  repaired  (hemostosis,  suture  of  gastro-intestinal  perfora- 
tions, etc.),  and  if  the  patient's  condition  permit,  the  surgeon  may 
open  the  thorax  and  suture  the  rent  in  the  diaphragm  from  above. 
If  collapse  of  the  patient  prevent  this  step  of  the  operation,  the  rup- 
ture should  be  tamponned  from  the  abdominal  wound,  in  the  hope  that 
prolective  adhesions  may  form.  Omentum,  and  even  liver  or  stomach 
might  be  sutuied  in  place  to  stop  the  gap. 

It  has  been  possible  to  find  references  only  to  five  operations  for 
subcutaneous  rupture  of  the  diaphragm.     Two  patients  recovered. 

1.  Guibal.    Laparotomy    by    Villemin:  herniated    organs    reduced; 

profuse  hemorrhage;  wound  hastily  tamponned.  Patiend  died 
in  a  few  minutes  after  return  to  bed.  Autopsy  showed  rupture 
of  spleen,  liver  and  left  kidney. 

2.  Walker.     Laparotomy:  small  bowel  withdrawn  from  rent,  which 

it  was  impossible  to  suture.     Recovered. 

3.  Knaggs.    Laparotomy  by  Berry,  5  days  after  injury;  hernia   re- 

duced; liver  sutured  against  rent  in  diaphragm.     Died  on  table. 

4.  Martin.     Operation  for  incarceiation  5  days  after  injury.     Died. 

5.  Suter.     Incision  as  for  nephrectomy;  suture  of  rents  in  diaphragm, 

and  left  nephrectomy.     Recovered. 
McGuire  (1914)  has  reported  a  successful  operation  for  diaphrag- 
matic hernia  seven  months  after  rupture  of  the  diaphragm  sustained 
in  a  fall  from  a  height  of  34  feet. 

(D)  Operative  Wounds  of  the  Diaphragm.— Iselin  (1907)  refers 
to  four  instances  of  operative  wounds  of  the  diaphragm,  recorded  by 
Humbert,  Leisrink,  Konig,  and  Hahn.  The  operations  of  Humbert, 
Leisrink  and  Konig  consisted  in  resecting  part  of  the  diaphragm  for 
sarcoma;  that  of  Hahn  was  for  enchondroma.  Humbert  and  Konig's 
patients  recovered,  but  those  of  Leisrink  and  Hahn  died. 


288  INJURIES    OF   DIAPHRAGM,    STOMACH   AND    DUODENUM 

n.  Injuries  of  the  Stomach. — From  its  anatomical  relations,  sur- 
rounded by  liver,  diaphragm,  pancreas,  colon,  and  spleen,  it  is  very 
rare  to  encounter  uncomplicated  wounds  of  the  stomach  (Fig.  71). 
Among  228  cases  of  penetrating  wounds  of  the  abdomen  collected  by 
Seigel  in  1898,  the  various  viscera  were  injured  as  follows: 

Viscus  injured  Stabwounds       Gunshot  wounds 

Stomach 4  71 

Small  intestine 12  52 

Liver 6  31 

Colon 5  IS 

Spleen  and  kidneys 2  14 

Omentum,  mesentery,  etc 3  •                         13 

32  196 

Of  532  cases  treated  without  operative  intervention,  238  recovered, 
and  294  died,  a  mortaUty  of  55.2  per  cent.  Of  376  cases  in  which 
operation  was  done,  182  recovered  and  194  died,  a  mortality  of  51.6 
per  cent.  The  difference,  when  the  figures  are  thus  given  between 
medical  and  surgical  treatment,  is  not  striking;  but  when  regard  is 
had  to  the  time  elapsing  between  the  accident  and  the  operation,  it  is 
quite  evident  that  surgery  offers  the  only  reasonable  hope  of  cure. 

Operations  for  Penetrating  Wounds  of  Abdomen 

Operation  Mortality 

Within  4  hours  of  injury 15  •  2  per  cent. 

From  5  to  8  hours  after  injury 44-4  per  cent. 

From  0  to  12  hours  after  injurj' 63.6  per  cent. 

More  than  12  hours  after  injury 70.0  per  cent. 

(A)  Stab-wounds. — The  stomach  is  one  of  the  organs  least  often 
wounded  in  penetrating  stabwounds  through  the  abdominal  wall. 
Among  75  instances  of  penetrating  wounds  of  the  stomach  collected 
by  Siegel,  there  were  only  4  cases  of  stabwound.  In  former  times 
bayonette  wounds  of  the  stomach  were  not  very  rare,  and  Tuffier 
(1907)  called  attention  to  the  fact  that  suicidal  stabwounds  are  n 
cause,  especially  in  women,  who,  in  aiming  at  the  supposed  locatioa 
of  their  heart  (below  the  left  breast),  usually  wound  the  fundus  of  the 
stomach. 

The  diagnosis  depends  more  upon  the  symptoms  than  upon  the 
position  of  the  wound.  In  rare  cases  the  stomach  may  be  penetrated 
by  a  stabwound  in  the  back  (Benoit).  As  previously  noted,  wounds 
of  the  stomach  are  not  infrequent  comphcations  of  transpleural  per- 


STAB-WOUNDS    OF    THE    STOMACH 


2S9 


forations  of  the  diaphragm  (p.  284).  Shock,  vomiting  of  blood,  and 
the  escape  of  gastric  contents  through  the  wound  may  render  the 
diagnosis  of  perforation  of  the  upper  intestinal  tract  certain;  but  in  all 
cases  the  wound  should  be  explored  before  peritonitis  has  had  time 
to  develope,  for  the  question  as  to  which  viscus  is  injured  is  of  rela- 
tively little  importance.  In  Lyng's  case  (1904)  there  was  no  doubt 
as  to  the  penetration  of  the  stomach,  since  the  instrument  (a  hayfork) 
which  produced  the  wound,  had  pieces  of  meat  and  potato  sticking 
to  it,  and  the  patient  had  just  finished  a  meal  composed  largely  of 
these  articles. 

Treatment.— li  protrusion  of  the  omentum  or  other  abdominal 
contents  renders  the  fact  of  pene- 
tration of  the  abdomen  certain,  no 
hesitancy  need  be  felt  in  freely 
opening  the  peritoneal  cavity;  but  if 
the  stab-wound  is  small  and  there 
is  doubt  as  to  whether  the  blade 
has  actually  entered  the  peritoneal 
cavity  cautious  exploration  should 
be  undertaken.  The  patient  being 
anesthetized,  and  prepared  as  for 
an  abdominal  operation,  the  sur- 
geon should  dissect  down  layer  by 
layer,  and  thus  follow  the  track 
of  the  wound.  It  is  sometimes 
impossible  to  follow  a  small  stab- 
wound  directly;  under  these  circum- 
stances it  is  best  to  lay  bare  the  abdominal  aponeurosis  (sheath  of  the 
rectus,  aponeurosis  of  external  oblique)  over  a  wide  area,  and  search 
it  carefully  for  the  stabwound.  If  this  cannot  be  found,  and  it  is 
known  that  the  blade  was  very  short  (that  of  a  pen-knife  for  example), 
and  if  there  are  no  other  symptoms  of  penetration,  the  skin  incision 
may  now  be  closed.  If,  however,  it  be  ascertained  that  the  blade  has 
penetrated  the  aponeurosis,  the  surgeon  should  next  lay  bare  the 
transversaUs  fascia  and  peritoneum,  but  should  not  open  the  latter 
until  he  is  sure  it  has  been  penetrated.  It  is  often  impossible  to  trace 
a  small  stabwound  across  fatty  tissue  and  muscular  fibres;  and  it  is 
usually  inadvisable  to  make  any  attempt  to  insert  a  probe  in  the  path 
of  the  wound,  as  by  doing  so  not  only  are  false  passages  usually  pro- 
duced, but  the  probe  itself  may  penetrate  the  abdominal  cavity  when 
the  latter  had  not  been  invaded  by  the  original  instrument.     But  by 


Fig.  71. — Diagram  to  Show  Overlap- 
ping of  Anterior  Gastric  Wall  by  Sur- 
rounding Structures. 


ago 


INJURIES    OF   DIAPHRAGM,    STOMACH   AND   DUODENUM 


arresting  his  dissection  at  the  aponeurotic  and  peritoneal  layers  of  the 
abdominal  wall,  the  surgeon  will  be  able  to  determine  in  almost  all 
cases  the  existence  or  the  absence  of  penetration  of  the  abdominal 
ca\'ity.  We  are  thus  insistent  upon  this  cautious  approach,  and  upon 
determining  beforehand  whether  the  peritoneal  cavity  has  been;pene- 
trated  by  the  weapon,  because  it  often  happens  that  on  opening  the 
abdomen  widely  in  these  cases  inspection  shows  no  evidence  of  intra- 
abdominal lesion,  and  verj'  extensive  search  becomes  necessary_  ;to 
exclude  the  possibiUty  of  visceral  injury ;  and  if  none  be  found  to  exist, 
and  it  is  shown  that  the  vulnerating  weapon  itself  had  never  opened 


Pig.  72. — Diagram  to  Show  Relations 
of  Posterior  Gastric  'Wall  to  Surrounding 
Structures. 


Fig.  73. — Diagram  Made  by  Superim- 
posing Fig.  71  on  Fig.  72  to  Show  Close 
Relations  of  Stomach  to  Surrounding 
Structures. 


the  peritoneal  cavity,  the  surgeon  will  have  subjected  his  patient 
to  a  quite  unnecessary  and  by  no  means  trivial  operation.  If,  how- 
ever, the  fact  of  abdominal  penetration  has  been  definitely  determined 
in  doubtful  cases  by  the  method  just  described,  the  surgeon  will  be 
quite  justified  in  his  extensive  intra-abdominal  manipulations,  even 
though  no  lesion  be  found  more  serious  than  hemorrhage  from  an 
omental  vein. 

Although  the  mortaUty  for  penetrating  stabwounds  of  the  abdo- 
men is  in  general  about  50  per  cent.,  yet  the  earher  the  operation,  the 
greater  the  chance  of  recover}-.  Siegel  found  that  for  those  patients 
operated  on  within  the  first  twenty-four  hours,  the  mortaUty  was  only 
8.7  per  cent.,  considerably  less  than  for  gunshot  wounds.  In  addition 
to  the  9  operations  for  isolated  stabwound  of  the  stomach  tabulated 
in  the  first  edition  of  this  work,  we  have  found  notes  of  a  tenth  such 


GUNSHOT    WOUNDS    OF   THE    STOMACH  29 1 

operation,  by  the  late  Prof.  John  Ashhurst,  Jr.,  at  the  Pennsylvania 
Hospital,  in  1897;  his  patient  did  not  recover,  so  of  the  ten  recorded 
operations,  the  mortality  was  20  per  cent. 

Stab-wotind  of  Right  Gastro-epiploic  Artery. — ]\Iaiocchi  reported 
in  1908  an  operation  for  a  large  hematoma  in  the  gastro-cohc  omentum 
due  to  a  stabwound  of  the  right  gastro-epiploic  artery,  without  other 
important  lesion. 

(B)  Gunshot  Wovinds  of  the  Stomach. — In  only  32  out  of  126 
cases  of  gunshot  injuries  of  the  stomach,  collected  by  Forgue  and 
Jeanbrau  (1903),  was  this  the  only  viscus  wounded;  in  other  words,  in 
about  three  out  of  every  four  cases  gunshot  wounds  of  the  stomach  are 
complicated  by  serious  injuries  of  neighboring  organs.  The  position 
of  the  stomach,  moreover,  is  such  that  not  only  will  it  be  liable  to 
injury  in  the  case  of  gunshot  wounds  of  the  abdomen,  but  also  in  those 
of  the  lower  thorax,  its  greater  tuberosity  reaching  as  high  as  the  fifth 
rib  on  the  left.  This  is  one  of  the  reasons  why  gunshot  wounds  of  the 
lower  thorax  give  a  higher  mortality,  and  more  urgently  call  for  opera- 
tive treatment  than  do  those  of  the  upper  portions. 

Gunshot  injuries  of  the  stomach  are  divided  by  systematic  writers 
into:  (i)  Perforations — usually  double,  there  being  one  wound  of  en- 
trance, and  another  of  exit;  (2)  Abrasions,  or  Excoriations — in  which 
the  gastric  wall  is  wounded  without  being  penetrated;  and  (3)  Con- 
tusions— which  may  affect  either  the  serous  or  the  mucous  aspect  of 
the  organ. 

The  occurrence  of  only  one  perforation  in  the  stomach  may  be 
explained  in  various  ways.  Among  112  cases  studied  by  Forgue  and 
Jeanbrau  (to  whose  excellent  monograph,  already  quoted,  surgeons 
are  indebted  for  most  of  their  modern  statistics),  in  only  13  did  no 
more  than  one  perforation  e.xist.  The  bail  may  never  have  entered 
the  stomach  at  all,  having  merely  struck,  it  a  glancing  blow,  sufficient 
to  penetrate  its  cavity,  but  because  of  its  tangential  course  passing  on 
without  traversing  this  cavity.  In  only  3  cases  was  the  bullet  known 
to  have  lodged  in  the  stomach.  It  may  make  its  exit  by  perforating 
the  duodenum  near  the  pylorus,  or  the  esophagus  close  to  the  cardia; 
and  it  is  even  conceivable  that  a  second  perforation  (wound  of  exit) 
may  occur  in  the  small  retroperitoneal  portion  of  the  gastric  wall  below 
the  cardia,  and  that  the  second  perforation  will  thus  be  impossible  of 
discovery  from  outside  the  stomach,  as  the  serous  covering  of  the 
organ  will  have  been  wounded  only  in  one  place.  Cases  are  on  record 
in  which  the  bullet,  entering  the  stomach,  has  been  passed  subse- 
quently by  the  bowel,  and  one  in  which  the  bullet  was  vomited. 


292  INJURIES    OF   DIAPHRAGM,    STOMACH   AND   DUODENUM 

According  to  Forgue  and  Jeanbrau  there  were  on  record  only  4 
cases  of  the  second  class  of  gunshot  wounds  of  the  stomach;  while 
contusions,  forming  the  third  class,  are  equally  rare.  In  a  patient  of 
their  own,  the  bullet  penetrated  and  lodged  in  the  stomach;  it  pro- 
duced a  contusion  (undiscovered  at  operation)  of  the  mucous  mem- 
brane of  the  opposite  wall.  Although  this  patient  did  well  for  three 
days  after  operation,  he  died  eventually  from  profuse  bleeding  into 
the  stomach  from  an  ulcer  which  formed  as  a  result  of  this  traumatism. 
A  distinction  is  to  be  drawn  between  gunshot  wounds  of  military, 
and  those  of  civil  life.  The  former  are  almost  always  rectihnear, 
owing  to  the  high  velocity  of  the  projectile;  and  the  bullet  as  a  rule 
perforates  the  patient's  entire  bod)',  unless  arrested  by  bone;  or  at 
least  lodges  beneath  the  skin  on  the  distal  side  of  the  body.  Bullets 
from  injuries  of  civil  life,  however,  are  more  easily  deflected  from  their 
course  on  entering  the  body,  and  rarely  if  ever  pass  completely  through 
the  trunk.  The  high  initial  velocity  of  the  modern  military  bullet 
gives  it  also  a  well  defined  explosive  action  on  a  hollow  \'iscus  if  filled 
with  fluid  or  semi-solid  matter,  pro\ided  the  range  be  less  than  400 
meters;  ci\'il  bullets,  on  the  contrary,  owing  to  their  much  lower 
velocity,  scarcely  ever  have  an  explosive  effect,  even  on  a  full  stomach. 
Wounds  by  shell  fragments  combine  the  evil  effects  of  missiles  of 
high  and  low  ^■elocity. 

Symptoms. — The  most  important  sjmiptoms  are  those  of  shock 
and  internal  hemorrhage.  Hematemesis  is  frequent.  Operation  should 
be  undertaken  before  evidences  of  peritonitis  have  time  to  develop. 

Diagnosis. — Though  perforation  of  the  stomach  may  be  suspected 
in  any  patient  in  whom  the  wound  of  entrance  lies  in  the  area  of  vul- 
nerability of  the  stomach  (see  Fig.  71),  and  also  in  certain  other  cases 
where  the  known  course  of  the  bullet  lies  in  the  direction  of  the  stomach, 
though  the  wound  of  entrance  may  be  at  some  distance  (loin,  thorax 
perineum,  etc.);  yet  the  only  certainty  consists  in  exploratory 
laparotomy. 

Prognosis. — Apart  from  the  method  of  treatment  adopted,  the 
condition  of  the  stomach  when  wounded  has  a  most  important  in- 
fluence on  the  prognosis.  If  the  stomach  be  empty,  and  the  patient 
remain  in  the  recumbent  position  after  the  injury  without  being  trans- 
ported for  a  great  distance,  extravasation  will  be  very  limited,  and  the 
development  of  peritonitis  much  delayed.  Forgue  and  Jeanbrau  in- 
clude in  their  study  45  patients  treated  without  operation,  and  82 
patients  treated  by  laparotomy.  In  the  case  of  the  former  patients 
the  death  rate  was  46  per  cent. ;  in  the  latter  it  was  42  per  cent.     Taking 


GUNSHOT   WOUNDS    OF    THE    STOMACH  293 

these  figures  as  they  stand,  they  do  not  seem  to  encourage  surgeons  in 
urging  laparotomy  as  a  hfe-saving  measure.  But  these  operations  are 
not  of  recent  date,  and  it  is  but  reasonable  to  suppose  that  the  imme- 
diate mortality  of  operations  for  gunshot  wounds  of  the  stomach  has 
improved  along  with  that  of  all  other  departments  of  gastric  surgery, 
since  the  date — 17  years  ago — when  these  studies  were  published. 
Accordingly  it  is  no  surprise  to  find  that  among  25  recently  reported 
operations  for  gunshot  wounds  of  the  stomach,  collected  in  1907  by 
Walton  Martin  of  New  York,  there  were  only  6  deaths — a  mortaUty  of 
less  than  25  per  cent.  And  although  it  is  probable  that  both  series  of 
statistics  give  too  favorable  a  prognosis,  being  founded  on  collected 
cases,  rather  than  on  a  consecutive  number  of  cases  treated  in  one  hos- 
pital, or  by  one  surgeon;  yet  their  comparative  value,  showing  a  marked 
reduction  in  the  mortaUty  after  modern  operations,  is  not  affected 
by  this  circumstance.  But  even  with  the  less  recent  figures  of  Forgue 
and  Jeanbrau,  a  Httle  closer  inspection  will  show  that  the  difference  be- 
tween the  results  of  expectant  and  operative  treatment  is  quite  con- 
spicuous. If,  for  example,  we  consider  apart  those  cases  in  which  the 
stomach  was  the  only  organ  injured,  and  those  in  which  the  gastric 
lesions  were  complicated  by  other  serious  injuries,  we  find  that  in  the 
former  class  of  patients  (19  cases),  operation  was  attended  by  a  mortality 
of  42.10  per  cent.,  while  among  the  latter  (63  cases)  the  death  rate  was 
68.25  pef  cent.;  if,  however,  no  operation  was  employed,  46  per  cent, 
of  those  patients  (13  cases)  with  only  gastric  lesions  died,  and  93  per  cent, 
of  those  (32  cases)  with  wounds  of  other  organs  succumbed.  As  it  is 
absolutely  impossible  to  know  before  beginning  the  operation  whether 
other  organs  besides  the  stomach  are  injured  or  not,  it  is  incumbent 
upon  the  surgeon  to  operate  on  all  cases,  in  order  to  decrease  the 
mortality  of  the  much  more  frequent  class  of  injuries  from  nearly  100 
to  less  than  70  per  cent. — or,  if  we  accept  Martin's  more  recent 
figures,  to  as  low  as  25  per  cent. 

In  military  practice,  gunshot  wounds  of  the  stomach,  as  of  other 
portions  of  the  gastro-intestinal  tract  are  almost  always  fatal.  No 
operation  can  be  undertaken  successfully  on  the  field  of  battle;  and 
unless  a  Mobile  Hospital  or  Auto-Chir.  is  established  very  near  the 
front,  well  equipped  for  prompt  abdominal  surgery,  such  patients 
are  either  already  dead,  or  peritonitis  is  so  far  advanced  as  to  render 
operation  unjustifiable  by  the  time  the  Base  Hospital  is  reached. 
Among  965  gunshot  wounds  of  the  abdomen  treated  by  operation, 
which  were  studied  by  Wallace  (1917),  there  were  82  which  involved 
the  stomach:  this  was  the  only  organ  wounded  in  55  cases,  and  among 


294 


INJURIES    OF   DIAPHRAGM,    STOMACH   AND   DUODENUM 


these  the  mortality  was  nearly  53  per  cent.;  in  27  cases  other  viscera 
were  wounded  as  well  as  the  stomach,  and  in  this  series  of  cases  the 
mortality  was  over  77  per  cent. 

The  importance  of  early  operation  in  civil  life  may  be  seen  from 
the  following  figures,  copied  from  Forgue  and  Jeanbrau: 


1.  Wounds  of  the  Stomach  Only 

Cases 

Recovered 

Died 

Mortality 
per  cent. 

Laparotomy  within  six  hours  of  injury .... 
Laparotom\'  after  unknown  lapse  of  time. 

13 
6 

19 

9 

2 

II 

4 
4 

S 

3° 
66 

42 

11.  Wounds  of  Other  Viscera  as 
Well  as  the  Stomach 

Cases   . 

Recovered 

Died 

Mortality 
per  cent. 

Laparotomy  during  first  six  hours 

Laparotomy  during  second  sLx  hours 

Laparotomy  after  lapse  of  twelve  hours. .  . 
Laparotomy  after  lapse  of  unknown  time. 

29 
13 
13 

8 

63 

13 
2 

2 
3 

20 

16 

II 

II 

5 

43 

55 
85 
85 
62 

68 

Treatment. — The  wound  in  the  abdominal  wall  should  •be  disin- 
fected, its  margins  being  excised,  and  any  particles  of  clothing  carried 
into  the  wound  (as  in  President  McKinley's  case)  should  be  removed. 
Discarding  the  instruments  used  for  this  purpose,  the  surgeon  should 
open  the  abdomen  by  an  epigastric  incision,  passing  through  the  left 
rectus  muscle  close  to  the  median  line.  It  is  proper  to  follow  the  track 
of  the  missile  only  when  there  is  reasonable  doubt  of  its  penetration. 
A  very  oblique  impact  in  a  patient  with  a  yery  fat  abdominal  wall 
may  result  in  the  missile  making  a  nonpenetrating  wound  involving 
only  the  abdominal  wall,  with  lodgment  of  the  bullet  in  the  flank,  the 
hypogastrium,  or  even  one  of  the  thighs.  But  in  the  vast  majority  of 
cases  there  will  be  no  doubt  of  the  bullet's  penetration;  and  under  these 
circumstances  a  median  incision  gives  the  best  exposure.  The  "  head 
high"  (reversed  Trendelenburg)  posture,  with  a  sandbag  under  the 
patient's  lower  dorsal  spine,  is  a  great  help  in  exposing  the  field  of 
operation.  Intrabdominal  hemorrhage  must  first  be  checked;  then 
the  search  for  perforations  is  begun.  The  stomach  is  to  be  located 
immediately  beneath  the  left  lobe  of  the  liver,  and  as  soon  as  a  perfora- 
tion is  found,  it  should  be  wiped  clean,  and  inverted  with  at  least  two 


GUNSHOT   WOUNDS    OF    THE    STOMACH  295 

rows  of  Lembert  sutures  of  fine  linen  thread.  The  first  tier  may  be  in 
the  form  of  a  pursestring  suture.  It  is  not  advisable  to  search  for  other 
perforations  until  the  first' has  been  sutured.  If  a  wound  of  exit  can- 
not be  found  on  the  anterior  wall  of  the  stomach,  the  gastro-colic 
omentum  should  be  divided,  between  clamps,  and  below  (on  the  colic  side 
of)  the  gastro-epiploic  arteries,  for  a  distance  at  least  of  locm. ;  (Fig.  159) 
or  the  intercolo-epiploic  route  (Fig.  11)  may  be  adopted.  A  free 
abdominal  incision  and  a  free  opening  in  the  gastro-colic  omentum 
will  do  much  to  hasten  the  subsequent  steps  of  the  operation.  The 
existence  of  a  perforation  in  the  posterior  wall  usually  will  be  indicated 
by  extravasation  within  the  lesser  peritoneal  cavity.  Baker's  diagnos- 
tic dose  of  methylene  blue,  taken  by  mouth  shortly  before  operation 
might  prove  useful  in  such  cases.  (See  p.  124.)  Walton  Martin 
states,  however,  that  among  the  cases  he  studied,  the  failure  to  suture 
the  bullet-hole  in  the  posterior  wall  of  the  stomach  had  not  materially 
influenced  the  mortality.  Should,  however,  a  perforation  be  detected 
in  a  position  which  was  inaccessible  to  suture,  the  surgeon  may  by 
gastrotomy  (incising  the  anterior  wall  of  the  stomach)  evert  the 
posterior  wall  through  the  gastric  incision,  and  suture  the  posterior 
perforation  from  its  mucous  surface.  Sometimes  the  perforation  in 
the  anterior  wall  of  the  stomach  is  not  accessible  through  a  median 
wound.  This  is  most  frequently  the  case  when  the  perforation  is  at 
the  fundus  or  near  the  cardia.  Under  such  circumstances  it  is  best 
to  adopt  temporary  resection  of  the  costal  margin,  after  the  plan  ad- 
vocated by  Auvray.  In  this  an  incision  is  made  from  the  upper  angle 
of  the  median  laparotomy  wound,  at  the  ensiform  process,  obliquely 
downward  to  the  tip  of  the  tenth  left  rib;  this  incision  is  carried  down 
to  the  costal  cartilages,  and  these  are  then  divided,  from  their  sternal 
attachment  outward,  including  if  necessary  the  cartilage  of  the  tenth 
rib  itself.  If  care  be  exercised  to  keep  the  line  of  incision  in  the 
cartilages,  and  not  to  invade  the  osseous  structure  of  the  ribs,  the 
pleural  cavity  will  not  be  opened.  By  pulHng  upward  on  the  costal 
border  thus  cut  loose,  the  transversahs  muscle  and  the  diaphragm  may 
be  detached  from  the  internal  aspect  of  the  ribs,  and  then  in  order  to 
open  the  peritoneal  cavity  it  only  remains  to  divide  the  peritoneum 
and  the  transversalis  fascia  (Forgue  and  Jeanbrau).  The  little  extra 
time  occupied  in  making  this  section  is  fully  justified  by  the  free  ex- 
posure it  gives  of  the  fundus  of  the  stomach.  Should  the  diaphragm 
have  been  perforated  by  the  bullet,  it  would  probably  be  better  to 
approach  this  region  of  the  stomach  by  the  transpleural  route  (p. 
286).     Whenever  the  gunshot  wound  traverses  the  thorax  and  wounds 


296  INJURIES    OF   DIAPHRAGM,    STOMACH   AND    DUODENUM 

the  abdominal  organs  the  question  will  arise  as  to  the  advisability  of 
draining  the  pleural  cavity.  Walton  ^Martin  advocated  drainage  of 
the  pleural  cavity  in  the  majority  of  such  cases;  but  we  are  inclined 
to  believe  it  is  safe  at  the  present  day  to  close  the  pleura,  and  only 
to  estabhsh  drainage  secondarily  if  an  empyema  develops. 

After  repairing  the  gastric  wounds,  search  must  be  made  for  other 
perforations,  in  the  colon,  the  duodenum,  and  neighboring  coils  of 
small  intestine.  Wounds  of  the  liver  and  spleen,  and  sometimes  those 
of  the  pancreas,  owing  to  the  free  hemorrhage  which  usually  attends 
them,  will  probably  have  received  attention  even  before  those  of  the 
stomach. 

Usually  sufficient  drainage  of  the  lesser  peritoneal  cavity  can  be 
obtained  by  a  cigarette  drain  carried  down  through  the  gastro-colic 
omentum.  In  rare  cases  it  is  advisable  to  make  drainage  through  the 
left  loin,  below,  or  even  above,  the  tip  of  the  twelfth  rib.  This  route 
was  particularly  studied  by  Mauclaire  (1902),  and  was  successfully 
employed  by  Hodge  (1908).  In  very  few  cases  will  it  be  safe  al- 
together to  dispense  with  drainage  of  the  lesser  peritoneal  cavity. 
This  should  never  be  done  if  there  is  the  least  suspicion  of  injury  to 
the  pancreas. 

The  clamps  left  on  the  cut  margin  of  the  gastro-colic  omentum 
are  now  used  as  tractors,  drawing  the  colon  up  against  the  stomach; 
and  by  their  aid  the  incision  in  this  structure  may  be  repaired  by 
sutures  (which  also  serve  for  hemostasis),  except  where  the  drain 
emerges.  If  the  operation  is  done  within  a  few  hours  of  injury  it 
will  not  be  necessary  to  leave  another  drain  to  the  sutured  area  on  the 
anterior  gastric  wall;  but  in  late  cases  this  should  be  done,  and  in  all 
cases  drainage  of  the  pelvis  should  be  established  through  a  supra- 
pubic incision. 

If  temporary  resection  of  the  costal  arch  have  been  employed,  it  will 
of  course  be  necessary  to  re-attach  the  diaphragm  to  the  lower  surface 
of  the  cartilaginous  flap,  and  to  restore  the  latter  to  its  place  by  the 
aid  of  deep  sutures  including  skin  and  intercostal  muscles. 

Should  suture  of  the  perforation  cause  stenosis  of  the  pylorus  or 
duodenum,  gastrojejunostomy  should  be  done  at  the  time  of  the 
primary  operation,  as  should  gastrostomy  if  obstruction  of  the  cardia 
was  produced. — In  desperate  cases  with  wounds  which  cannot  be 
repaired,  the  surgeon  must  rely  on  a  rubber  tube  passed  into  the 
perforation,  and  cautiously  surrounded  by  gauze  packs. 

(C)  Rupture  of  the  Stomach. — This  may  be  either  the  so-called 
^'spontaneous''  rupture,  or  the  traumatic  variety. 


SPONTANEOUS  RUPTURE  OF  THE  STOMACH  2Q7 

(i)  Under  the  name  spontaneous  ruptiire  of  the  stomach  certain 
cases  have  been  reported,  some  of  which  are  more  accurately  des- 
cribed as  ruptures  from  within  (pseudo-spontaneous  ruptures),  since 
they  were  cleaily  due  to  the  trauma  inflicted  by  lavage.  Long  ago, 
Orth  recorded  a  fatal  gastric  hemorrhage  from  the  passage  of  a  stomach 
tube;  and  Key  Aborg  and  Strassmann  have  each  observed  multiple 
ruptures  of  the  gastric  mucosa,  as  the  result  of  too  forceful  lavage 
in  patients  dying  of  opium  poisoning.  In  another  patient  of 
Strassmann 's,  with  gastric  cancer,  complete  rupture  of  the  gastric 
wall  was  produced  by  lavage,  and  at  autopsy  the  stomach  contents 
were  found  in  the  peritoneal  cavity.  In  a  patient  of  Wunscheim's  a 
carcinoma  of  the  esophagus  ruptured  into  the  aorta  after  the  passage 
of  a  sound,  and  at  autopsy  there  were  also  found  rents  in  the  mucous 
coat  of  the  stomach.  Haberda  has  reported  a  fatal  case  of  complete 
rupture  of  the  stomach  due  to  its  artificial  distention  with  air;  Ungar 
observed  a  similarly,  fatal  case  due  to  the  distention  of  the  stomach 
produced  by  swallowing  effervescent  powders;  and  Bardachzi  (191 1) 
recorded  another  case  in  which  free  hemorrhage  and  tetanoid  cramps 
followed  the  administration  of  a  Seidlitz  powder  in  two  parts.  Though 
recovery  ensued  in  this  case,  a  second  patient  with  gastric  carcinoma 
died  in  collapse,  apparently  from  interference  with  the  heart's  action. 

These  ruptures  from  over-distention  are  more  frequent  along  the 
lesser  curvature,  radiating  from  the  cardia.  They  have  been  par- 
ticularly studied  by  Key  Aborg  (1891)  and  by  Fraenckel  (igoy),  each 
of  whom  conducted  experiments  to  test  the  elasticity  of  the  stomach, 
and  its  most  frequent  site  of  rupture.  With  a  view  to  preventing 
rupture,  it  is  above  all  things  important  to  perform  lavage  with  gentle- 
ness, and  at  leisure;  especially  is  this  the  case  with  patients  whose 
stomachs  are  known  to  be  seriously  diseased,  and  in  those  who  are 
unconscious,  since  the  sensations  of  the  patient  form  a  very  valuable 
guide  to  the  quantity  of  fluid  which  may  safely  be  introduced  into 
the  stomach. 

True  spontaneous  ruptures  appear  to  have  been  recorded  in  about 
a  dozen  instances.  Abstracts  of  these  cases  follow,  the  first  seven 
references  being  quoted  from  the  well  known  paper  on  injuries  of  the 
stomach  by  Petry,  1896: 

I.  Brush.  Sudden  pain  and  collapse  during  effort  to  lift  a  stone; 
slow  recovery  without  operation.  For  forty  years  suffered  from 
gastric  troubles.  At  autopsy  there  was  found  a  gastro-pan- 
creatico-duodenal    fistula;    the    pylorus    was    tightly    stenosed. 


298  INJURIES    OF   DIAPHRAGM,    STOM.A.CH   AND    DUODENUM 

This  case  appears  rather  apocryphal  in  the  light  of  modern 
knowledge. 

2.  XewTnan.     Insane  patient;  during  violent  vomiting  after  meal, 

developed  pain,  collapse,  tympany,  subcutaneous  emphysema. 
Rupture  of  entire  gastric  waU  found  at  autopsy. 

3.  ReviUiod.     Spontaneous   rupture   from   fermentative   distention. 

Autopsy  showed  no  ulcer;  two  ruptures  in  serous  coat. 

4.  HofTman.     Spontaneous    rupture    from    fermentative    distention. 

Death. 

5.  Thompson.     Spontaneous    rupture    from    unknown    cause.     No 

injury. 

6.  Lantschner.     Stomach  in  umbilical  hernia.     After  drinking  im- 

mense quantit)'  of  water  and  tea,  rupture  caused  by  vomiting. 
Died. 

7.  Chiari.     Spontaneous  rupture  from  fermentative  distention.     Au- 

topsy showed  longitudinal  rupture  in  scar  of  old  ulcer. 

8.  Hartmann    (1906).     Spontaneous   rupture;    autopsy   showed    ex- 

treme atrophy  of  gastric  walls.     (Perhaps  auto-digestion.) 
Q.  Ipsen  (1907).     Spontaneous  rupture  from  vomiting.     Death. 

10.  Wilke   (1907).     Autopsy  on  patient  with   \oh'ulus  of  stomach, 

showed  rupture  of  its  posterior  wall  causing  death  from  peri- 
tonitis. 

11.  Ambrose    (1908).     Spontaneous  rupture  while  stooping.     Opera- 

tion i}^  hours  later  showed  a  sHt  i  in.  long  near  pylorus  on 
margins    of    chronic    ulcer.     Partial    gastrectomy.     Recovery. 

12.  0111(1918).     Girl  aged  16  years,  with  healed  kyphos  (tuberculous). 

Death  in  collapse  after  illness  of  few  hours  duration,  with  symp- 
toms of  acute  dilatatian  of  stomach.  Autopsy  showed  a  complete 
rupture  2.5  cm.  long  on  anterior  wall  near  greater  curvature, 
5  cm.  below  cardiac  end,  with  radiating  rents  in  the  mucosa. 

As  pointed  out  by  Doujon  (1903),  it  is  quite  probable  that  some 
form  of  gastric  volvulus,  self  reduced  before  death,  or  undiscovered 
at  autopsy,  is  the  chief  cause  of  such  spontaneous  ruptures  in  ap- 
parently healthy  stomachs;  and  the  case  since  reported  by  Wilke, 
and  above  quoted,  supports  this  view.  Strassmann  (1907)  suggested 
that  these  mucous  lacerations  may  be  much  more  frequent  than  is 
generally  appreciated,  and  questioned  whether  they  might  not  form 
the  initial  stage  of  gastric  ulcer  or  carcinoma.  As  already  mentioned, 
other  writers  seem  to  have  had  the  same  idea.     (See  p.  245.) 

According  to  Rehn  (1S96),  spontaneous  rupture  from  gaseous  dis- 


TRAUMATIC   RUPTURE    OF    THE    STOMACH  299 

tention  is  not  very  rare  in  horses,  but  generally  is  observed  along  the 
greater  curvature. 

Gastric  hemorrhages,  possibly  due  to  ruptures  of  the  mucosa, 
have  been  observed  in  patients  who  have  fallen  on  the  back,  on  the 
buttocks,  and  even  in  one  injured  by  a  "general  shaking  up."  (Strass- 
mann,  loc.  cit.,  S.  i66.) 

(2)  Traumatic  Rupture  of  the  Stomach.^This  is  usually  accom- 
panied by  such  extensive  visceral  injuries  as  to  terminate  fatally 
before  surgical  treatment  can  be  instituted.  Geill  in  eight  and  a  half 
years  found  35  ruptures  of  the  stomach  at  autopsy  in  Vienna,  and 
Strassmann  observed  about  the  same  number  at  autopsies  in  Berlin, 
during  about  fifteen  years.  Two  such  cases  have  been  observed  at  the 
Episcopal  Hospital,  Philadelphia  (1901  and  1910):  in  the  first  case  the 
lesion  was  founa  at  autopsy;  but  in  the  second  case  operation  was  done 
(by  the  junior  author),  but  the  patient  died  within  an  hour.  As  an 
injury  which  interests  surgeons  it  must  be  considered  rare. 

The  causes  are  blows,  falls,  and  crushes,  especially  the  last.  Kicks 
by  horses  are  also  a  frequent  cause. 

Rehn  (1896)  divided  ruptures  of  the  stomach  into  (i)  those  involving 
only  the  serous  coat;  (2)  those  affecting  the  serous  and  muscular  coats; 

(3)  interstitial    ruptures,    including    submucous    hematomata,    etc.; 

(4)  ruptures  of  the  mucosa;  (5)  penetrating  ruptures — those  in  which 
the  entire  thickness  of  the  gastric  wall  is  involved.  From  the  ex- 
periments conducted  by  Fraenckel  and  others,  it  appears  that  mucous 
ruptures  are  usually  produced  by  overdistention  from  within;  that 
ruptures  of  the  serous  coat  alone  are  frequently  the  result  of  external 
pressure  on  a  distended  stomach;  that  contusions  result  in  interstitial 
ruptures;  and  that  complete  ruptures  are  more  apt  to  be  caused  by  crush- 
ing of  the  stomach  against  the  spinal  column. 

Petry  (1896)  in  his  study  of  subcutaneous  ruptures  of  the  aUmentary 
canal,  found  the  stomach  involved  in  21  cases,  the  small  bowel  in 
172  (of  which  9  were  duodenal  ruptures),  and  the  large  bowel  in  26 
cases.  Of  the  2  gastric  ruptures,  eight  he  termed  spontaneous,  in- 
cluding here  the  case  reported  by  Key  Aborg  (which  we  have  classed 
as  pseudo-spontaneous).  These  cases  have  alieady  been  discussed 
(p.  297).  Of  the  13  traumatic  ruptures,  two  were  submitted  to  opera- 
tion; death  quickly  ensued  in  five  of  the  remaining  patients  (11  in 
number),  on  whom  no  operation  was  done.  Of  the  six  patients,  who 
survived  without  operation,  two  recovered  with  gastro-cutaneous  fistu- 
las, two  were  operated  on  after  4  and  2  weeks  respectively,  for  perigastric 
abscesses,  but  eventually  recovered;  while  in  the  remaining  two  pa- 


300  INJURIES    OF   DIAPHRAGM,    STOMACH   AND   DUODENUM 

tients,  traumatic  ulcers  formed,  which  subsequently  necessitated 
further  treatment.  Tawastsjerna  collected,  in  1905,  125  cases  of  opera- 
tion for  subcutaneous  rupture  of  the  abdominal  viscera,  all  that  had 
been  recorded  since  the  publication  of  the  paper  by  Petry,  mentioned 
above.  Of  these  more  recent  cases,  41  recovered,'  and  84  died,  a 
death  rate  of  67.2  per  cent.  Meerwein  in  1907  studied  93  operations 
for  subcutaneous  rupture  of  the  abdominal  \dscera,  recorded  since 
1896.  He  found  that  among  69  patients  operated  on  within  24  hours 
of  the  injury,  38  died,  a  mortality  of  55.1  per  cent.;  while  of  24  pa- 
tients who  were  not  operated  on  until  more  than  24  hours  had  elapsed, 
no  less  than  14  died,  a  mortality  of  66.7  per  cent.  Although  these 
figures  probably  are  relatively  correct,  in  that  they  show  the  value  of 
early  operation  as  a  life  saving  measure,  there  is  also  no  doubt  that, 
as  Meerwein  points  out,  these  results  are  much  more  favorable  than 
are  actually  obtained  in  any  consecutive  series  of  cases.  To  support 
this  assertion,  ^Meerwein  quotes  the  following  series  of  operations  for 
rupture  of  the  abdominal  viscera. 


,    .1.    •.  No.  of     ,  ^  J  I      T^-  J        Mortality 

Autnonty  '  .       -  Recovered !      Died 

operations  per  cent. 


20 

95- 

6 

85. 

12 

85- 

16 

94- 

15 

88. 

15 

83- 

7 

58. 

>-2 

)-7 
2  12  85.7 

I  16  '        Q4.I 

.2 


Neumann 21 

Schmitt 7 

Voswinckel 14 

Hagen 17 

Thommen 17 

Basel  clinique '^1           ^                  15         i       83.3 

Hildebrand 12        I          5                   7               58.3 

106        j         15  91         I       85,8 


It  should  be  noted  that  the  cases  reported  by  Hildebrand  have  all  been 
treated  within  recent  years. 

Only  eight  operations  for  traumatic  rupture  of  the  stomach  appear 
to  have  been  recorded.  The  patient  of  Mikulicz  (1885)  had  been  drink- 
ing heavily,  and  was  taken  with  sudden  abdominal  pain,  followed  by 
extreme  tympany  and  collapse.  Mikulicz  first  punctured  the  ab- 
domen; the  gas  which  escaped  was  inflammable,  and  smelled  strongly 
of  alcohol.  By  laparotomy  a  rupture  of  the  lesser  curvature  was 
sutured,  but  the  patient  died  three  hours  later.  Although  the  stomach 
evidently  was  diseased  prior  to  the  time  of  rupture,  it  was  the  ooinion 
of  Mikulicz  that  the  rupture  was  traumatic  in  origin,  due  either^to 
distention  from  within  the  stomach  or  to  unrecorded  external  injury. 


TRAUMATIC   RUPTURE    OF   THE    STOMACH  30I 

Rehn's  patient  (1896)  fell  from  a  second  story  window,  but  recovered 
after  prompt  suture  of  the  rent  in  the  stomach.  The  patients  operated 
on  by  Thommen  and  by  Korte  both  died;  but  Thommen's  patient 
(1902)  lived  four  days,  and  death  was  found  at  autopsy  to  be  due  to 
rupture  of  the  duodenum  undiscovered  when  the  rupture  of  the  stomach 
was  sutured.  Allivasato's  (1909)  and  Rodocanache's  (1911)  patients 
recovered;  but  Singley's  (1913)  died  in  7  hours.  The  history  of  Ash- 
hurst's  patient  (already  mentioned  at  p.  299)  is  as  follows: 

Charles  B.,  7  years  of  age,  was  brought  by  ambulance  to  the  Episcopal  Hospital,  at 
1.30  P.M.,  Nov.  16,  1910.  Thirty  minutes  previously,  soon  after  his  midday  meal,  he  had 
been  knocked  down  by  a  heavy  wagon,  the  wheels  passing  across  his  epigastrium.  He 
vomited  a  little  blood,  and  was  in  a  state  of  shock;  his  temperature  was  subnormal,  his 
pulse  rapid  and  fluttering;  and  his  lips  were  blue.  The  abdomen  was  a  little  distended 
and  tympanitic;  and  anteriorly  the  liver  dulness  was  replaced  by  tympany.  There  was 
dulness,  however,  in  the  right  flank.  There  was  much  abdominal  pain,  but  no  rigidity. 
One  hour  later  it  was  noted  that  the  pulse  rate  was  140,  that  the  child  was  thirsty,  and  that 
there  was  sighing  respiration.  A  diagnosis  was  made  of  internal  hemorrhage,  probably 
accompanied  by  rupture  of  a  hollow  viscus. 

Operation  (Dr.  Ashhurst),  2  hours  after  injury  (Ether):  Paramedian  epigastric  inci- 
sion from  ensiform  to  navel;  liquid  blood  and  particles  food  (chiefly  boiled  potato)  poured 
forth.  Packs  were  inserted  to  the  left  and  below,  exposing  the  pylorus.  Blood  poured 
from  above  the  stomach.  The  gastrohepatic  omentum  was  ruptured,  and  about  100  cc. 
blood  clots  and  an  equal  amount  of  food  lay  between  the  stomach  and  the  left  lobe  of  the 
liver,  in  the  lesser  peritoneal  cavity.  On  the  posterior  wall  of  the  stomach  near  the  lesser 
curvature  was  a  large  circular  rupture  (about  4  cm.  in  diameter),  with  the  mucous  mem- 
brane everted  into  the  opening.  The  patient's  lower  dorsal  spine  was  now  raised  on  a 
support,  as  in  operations  on  the  biliary  tract,  to  secure  better  exposure.  The  rupture  in 
the  stomach  was  closed  with  two  layers  of  sero-serous  sutures.  The  continuous  ooze  of 
blood  from  the  structures  beneath  the  peritoneum  forming  the  posterior  wall  of  the  lesser 
peritoneal  cavity,  and  from  several  small  ruptures  on  the  under  surface  of  the  left  lobe  of 
the  liver,  was  controlled  by  three  gauze  packs,  emerging  through  the  gastrohepatic  omen- 
tum. The  epigastric  incision  was  closed  with  through-and-through  sutures  of  silkworm  gut, 
and  a  glass  tube  was  placed  through  a  suprapubic  stab-wound,  to  drain  the  pelvis.  Pieces 
of  boiled  potato  floated  out  of  this  tube.  During  the  operation,  which  lasted  one  hour, 
the  patient  received  1500  cc.  of  saline  solution,  with  adrenalin,  intravenously. 

Death  occurred  a  little  niore  than  an  hour  after  his  return  to  bed. 

'  Interstitial  ruptures  of  the  stomach  may  cause  (i)  Hematoma; 
(2)  Cyst;  (3)  Abscess.  This  subject  has  been  made  the  subject  of 
an  interesting  monograph  by  Pedro  Chutro,  of  Buenos  Aires,  and 
it  is  from  his  work  (1905)  that  most  of  what  follows  has  been  ab- 
stracted. Rupture  of  a  vessel  in  the  submucosa  is  possibly  the  first 
lesion;  and  the  hematoma  which  forms  may  be  gradually  absorbed, 
without  producing  very  acute  symptoms.  If  of  large  size,  however,  a 
cyst  will  form,  and  usually  this  cyst  becomes  more  or  less  infected  from 
transudation  through  the  mucous  membrane  which  forms  one  of  its  walls 
(p.  214).     A  certain  amount  of  gastric  juice  may  be  secreted  directly 


302  INJURIES    OF   DIAPHRAGM,    STOMACH   AND   DUODENUM 

into  the  cyst,  from  the  deep  layer  of  the  mucosa.  By  some  such 
process  as  this  there  is  formed  an  abscess,  which  in  the  patient  on  whom 
Chutro  operated  resembled  a  cold  abscess  in  character.  Zeigler  op- 
erated on  a  patient  who  had  received  an  abdominal  injury  some  weeks 
previously;  he  found  a  large  hematoma  in  the  anterior  wall  of  the 
stomach;  recovery  was  uneventful.  Similar  cases,  without,  however 
a  history  of  injury,  have  been  recorded  by  Sloane  and  Anderson. 
Sloane's  patient  died  from  typhoid  fever,  and  the  gastric  condition 
was  not  suspected  during  Ufe.  Anderson's  patient  died  after  the 
hematoma  had  been  drained  by  laparotomy.  Rendu  operated  on  a 
patient  with  an  infected  cyst  of  the  gastric  wall;  death  occurred  from 
peritonitis.  Gallois,  Houlong  and  Leflaive  recorded  a  case  where 
death  was  due  to  rupture  of  a  cyst  of  the  posterior  wall  of  the  stomach. 
Chutro's  own  patient,  a  boy  of  g  years,  received  a  kick  from  a  horse 
in  the  epigastric  region;  19  days  later  an  interstitial  abscess  in  the 
posterior  gastric  wall  was  opened  and  drained  by  laparatomy;  un- 
eventful recovery  ensued.  Although  a  history  of  injury  is  certain 
only  in  the  patients  of  Zeigler  and  Chutro,  it  seem  proper  to  mention 
the  others  in  this  place,  in  view  of  what  we  have  already  learned  of 
the  character  of  mucous  and  spontaneous  ruptures  of  the  stomach. 

Menne  (1905)  made  an  extensive  study  of  the  after  effects  of 
injviries  of  the  stomach.  He  collected  51  cases  in  which  lesions  of 
the  gastric  mucosa  (ulcer,  stenosis,  etc.)  followed  trauma,  45  being 
due  to  direct,  and  5  to  indirect  violence,  while  in  one  case  the  nature 
of  the  injur}'  was  not  stated.  In  24  cases  the  injury  was  produced  by 
moving  bodies  impinging  upon  the  patient's  abdomen,  and  in  27 
cases  it  was  caused  by  the  collision  of  the  patient  with  bodies  at  rest. 
He  further  tabulates  8  cases  of  gastric  hemorrhage  or  perforation  due 
to  more  or  less  indirect  injuries,  such  as  muscular  efforts,  etc. 

Rupture  of  Right  Gastro-epiploic  Artery. — An  isolated  case  of 
this  nature,  accompanied  by  an  insignificant  tear  in  the  margin  of 
the  liver,  due  to  the  kick  of  a  horse,  has  been  recorded  by  Vattcr 
(1904).  Laparotomy  was  done  on  account  of  symptoms  of  internal 
hemorrhage;  the  artery  was  ligated,  and  recovery  ensued.  One  case 
of  rupture  of  the  gastro  colic  omentum  and  one  of  rupture  of  the  gastro- 
hepatic  omentum  have  been  operated  on  at  the  Episcopal  Hospital 
by  the  junior  author.  The  first  patient  (1909),  a  man  aged  64  years, 
came  to  operation  23  hours  after  being  struck  in  the  epigastrium  by 
the  end  of  a  swinging  cable.  On  opening  the  abdomen  immense 
quantities  of  blood  were  found,  and  the  patient,  whose  pulse  stopped 
and  who  ceased  to  breathe,  was  only  revived  by  direct  massage  of  the 


FOREIGN  BODIES    IN   THE   STOMACH  303 

heart  through  the  abdominal  wound.  The  only  lesion  found  was 
a  rupture  o£  the  gastro-colic  omentum  still  oozing  blood.  The  patient 
had  an  irreducible  left  scrotal  epiplocele,  which,  holding  the  omentum 
taut,  evidently  predisposed  to  injury.  The  patient  died  3  hours  after 
the  end  of  the  operation.  In  the  second  case  (191 2),  a  boy  4  years  of 
age  who  came  to  operation  2}4  hours  after  injury,  there  was  a  rupture 
of  the  spleen  in  addition  to  rupture  of  the  gastro-hepatic  omentum. 
The  patient  died  with  symptoms  of  sepsis  55  hours  after  operation; 
autopsy,  however,  showed  no  evidences  of  peritonitis  nor  of  further 
intraperitoneal  hemorrhage. 

(D)  Foreign  Bodies  in  the  Stomach. — Children,  insane  people, 
and  mountebanks  form  the  chief  classes  of  patients  to  be  considered 
here.  Others  by  mistake  occasionally  swallow  a  tooth-plate,  a  piece 
of  bone,  or  some  similar  object.  Children  most  frequently  swallow 
coins,  buttons,  pins,  etc.  The  insane  swallow  almost  everything; 
hair  swallowing  is  done  only  by  those  with  neurotic  taint,  frequently 
during  convalescence  from  some  debilitating  disease,  such  as  typhoid 
fever.  Sword  swallowers  occasionally  try  to  exhibit  their  art  with 
too  short  a  knife;  it  may  slip  from  their  grasp  and  be  hurried  into  the 
stomach  by  involuntary  efforts  at  swallowing.  Pieces  of  glass,  nails, 
and  all  manner  of  articles  are  sometimes  swallowed  by  showmen. 

The  majority  of  such  articles  as  pass  through  the  straits  of  the 
esophagus  and  reach  the  stomach  without  difficulty  will  also  pass  the 
pylorus,  traverse  the  intestinal  tract,  and  be  discharged  from  the  anus 
in  the  course  of  a  few  days  without  producing  any  symptoms.  The 
form,  consistency,  and  bulk  of  the  article  swallowed,  are,  in  the  order 
mentioned,  the  characters  which  have  most  influence  on  the  prognosis. 
Bodies  of  rounded  form,  such  as  coins,  or  at  least  those  which  have  no 
prongs  or  sharp  angles,  will  usually  pass  without  trouble.  Certain 
other  articles,  such  as  pieces  of  bone,  may  become  partially  digested 
in  the  stomach,  and  may  thus,  with  their  sharp  angles  rounded  off,  be 
discharged  without  causing  injury  to  the  gastro-intestinal  tract.  As 
far  as  the  stomach  is  concerned,  the  size  of  the  body  swallowed  is  the 
least  important  factor  in  the  prognosis,  as  it  is  almost  certain  that 
articles  which  can  pass  the  cardiac  orifice  can  also  pass  the  pylorus. 
This  remark,  however,  does  not  apply  to  long  nails,  slate-pencils, 
knives  and  forks,  in  which  form  is  of  greater  importance  than  mere  bulk. 

Occasionally,  as  in  children  and  in  the  insane,  no  history  of  swallow- 
ing a  foreign  body  can  be  obtained.  Apart  from  such  a  history,  the 
symptoms  of  the  lodgment  of  a  foreign  body  in  the  stomach  are 
chiefly  those  of  pain  and  vomiting.     The  latter  may  be  persistent,  and 


304  INJURIES    OF   DIAPHRAGM,    STOMACH   AND   DUODENUM 

the  vomitus  may  be  streaked  with  blood.  In  other  cases,  in  spite  of 
pain,  no  nausea  is  present,  and  appetite  may  even  be  preserved. 

The  diagnosis  in  acute  cases  is  rarely  difficult,  because  of  the 
history.  But  it  is  frequently  difficult  to  determine  the  presence  of 
hair  tumors  (Egagropile,  Trichobezoar)  before  operation,  because  the 
patient  either  is  not  aware  that  she  has  been  in  the  habit  of  swallowing 
her  hair,  or  she  is  unwilling  to  acknowledge  the  habit.  In  the  insane 
the  diagnosis  may  be  impossible  without  the  aid  of  the  Roentgen  rays. 
The  subject  of  hair-balls  in  the  stomach  was  studied  by  Matas  in 
1 91 5:  he  collected  73  cases;  44  of  the  patients  came  to  operation. 
Among  28  operations  for  hair-balls  in  the  stomach  analyzed  by  Moore 
(1914),  2  patients  died,  a  mortality  of  7  per  cent. 

If  the  foreign  body  remain  in  the  stomach,  it  may  be  quiescent  for 
long  periods;  it  may,  on  the  other  hand,  cause  ulceration,  perigastritis, 
subacute  perforation,  and  finally  a  subcutaneous  abscess;  in  rare 
instances  it  may  directly  perforate  the  gastric  wall. 

The  treatment  to  be  adopted  depends  on  the  nature  of  the  body 
swallowed.  If  certain  to  pass,  the  Vienna  treatment,  advocated  long 
ago  by  Billroth,  should  be  employed.  This  consists  of  a  diet  of  mashed 
potatoes,  or  such  similar  substances  as  will  tend  to  coat  the  foreign 
body  and  aid  its  passage  through  the  intestinal  tract.  When  once 
out  of  the  stomach,  it  is  most  apt  to  be  arrested  at  some  point  in  the 
lower  ileum.  Under  no  circumstances  should  a  purge  be  given.  The 
violent  peristalsis  thus  aroused  is  much  more  likely  to  cause  perforation 
of  the  stomach  or  bowel,  or  intestinal  obstruction  from  inflammatory 
edema,  than  to  promote  the  passage  of  the  foreign  body  through  the 
intestinal  tract.  If  no  symptoms  are  produced  by  the  swallowed 
article,  there  need  be  no  haste  in  resorting  to  operation,  even  if  it  is 
manifestly  impossible  for  the  foreign  body  to  escape  from  the  stomach. 
The  Roentgen  rays  may  be  employed,  and  the  location  of  the  offending 
substance  determined.  As  its  weight  may  cause  the  stomach  to 
descend  much  below  its  normal  position,  it  may  appear  that  the 
foreign  body  is  in  the  large  bowel  (especially  the  cecum)  instead  of 
in  the  stomach.  The  passage  of  a  stomach  tube,  or  the  introduction 
of  bismuth  emulsion  into  the  stomach  Just  before  a  second  skiagraph 
is  made,  probably  will  determine  the  question. 

Gastrotomy  is  indicated  (i)  when  it  is  clearly  impossible  for  a 
quiescent  foreign  body  to  be  discharged  spontaneously;  (2)  when  any 
symptoms  arise  from  any  variety  of  foreign  body ;  (3)  it  is  occasionally 
required  for  the  removal  of  a  foreign  body  impacted  in  the  lower  end  of 
the  esophagus.     The  use  of  endogastric  instruments,  as  employed  by 


FOREIGN  BODIES  IN  THE  STOMACH  305 

Chevalier  Jackson,  is  justifiable  only  in  the  hands  of  a  specialist.  The 
average  surgeon  will  consult  his  patient's  safety  much  more  by  resort- 
ing to  gastrotomy. 

This  operation,  for  this  purpose,  is  said  to  have  been  first  done  by 
Daniel  Schwabe  in  1635.  His  patient,  operated  on  without  an  an- 
esthetic, recovered.  It  was  not  until  1848  that  the  operation  was 
repeated,  by  Tilanus.  In  1887  Bernays  collected  11  cases  of  gastro- 
tomy for  foreign  bodies,  including  one  of  his  own;  he  also  referred  to 
16  other  operations  which  consisted  in  extracting  foreign  bodies  from 
the  stomach  after  this  viscus  had  become  adherent  to  the  parietal 
peritoneum  as  the  result  of  perigastritis  set  up  by  the  foreign  body. 
Of  the  II  patients  in  the  former  series,  only  2  died.  The  late  Prof. 
Ashhurst  (1893)  referred  to  50  cases  of  gastrotomy  for  the  extraction  of 
foreign  bodies,  42  of  which  terminated  in  recovery.  He  says  that 
"foreign  bodies  which  have  been  swallowed,  and  having  ulcerated 
through  the  walls  of  the  stomach,  had  lodged  in  various  parts  of  the 
abdominal  cavity,  have  been  successfully  removed  by  LeDentu,  Bar- 
deleben  (two  cases),  Nussbaum  (two  cases),  LeFillier,  and  Dubois." 

Among  20  recent  cases  of  gastrotomy  for  foreign  body,  references 
to  which  were  given  in  our  first  edition,  there  was  only  i  death,  a 
mortality  of  5  per  cent;  and  among  23  operations  reported  since  that 
date  there  was  only  i  death, ^  so  that  the  operation  may  be  considered 
reasonably  safe.  Two  patients  (professional  "sword-swallowers") 
whose  cases  are  recorded  by  Revenstorf  (1904)  and  by  Warbasse 
(1904),  were  operated  on  twice  both  times  successfully.  Winslow 
(1919)  has  reported  a  successful  case  of  gastrotomy  with  removal  1290 
different  foreign  bodies. 

The  operation  consists  (i)  in  opening  the  abdomen  through  the 
left  rectus  muscle,  (2)  in  locating  the  stomach;  (3)  in  drawing  the 
stomach  into  the  wound,  and  isolating  it  by  gauze  packs;  (4)  opening 
the  stomach,  preferably  b}'  an  incision  transverse  to  its  long  axis;  (5) 
removing  the  foreign  body  by  forceps  or  fingers;  (6)  suturing  the  gas- 
tric incision  with  at  least  two  rows  of  Lembert  sutures,  or  one  of  the 
Czerny  and  one  of  the  Lembert  type;  (7)  closing  the  abdominal  wound. 

The  incision  in  the  stomach  should  be  no  longer  than  is  absolutely 
requisite  for  the  extraction  of  the  foreign  body.  It  is  well  to  locate  the 
body  and  fix  it  against  a  convenient  portion  of  the  gastric  wall  before 
opening  the  stomach.  Should  it  be  impossible  to  remove  a  body  im- 
pacted in   the  lower   esophagus,    gastrostomy   should  be  performed; 

'  This  series  of  operations  includes  one  patient,  reported  by  Wolff  (1913),  who  had  had 
no  less  than  five  separate  gastrotomies  done  at  various  times. 
20 


3o6  INJURIES    OF   DIAPHRAGM,    STOMACH   AND   DUODENUM 

this  procedure  was  necessary  in  a  patient  under  Jacobson's  care  in 
1889;  unfortunately  the  patient  did  not  survive  more  than  two  days. 
In  a  similar  case  recorded  in  1900  by  Edmunds  a  tooth-plate  was  suc- 
cessfully removed  from  the  lower  esophagus  by  gastrotomy. 

in.  Injuries  of  the  Duodenum. — Injuries  of  the  first  portion  of 
the  intestinal  tract  differ  from  those  of  other  portions  chiefiy  on  account 
of  the  situation  of  the  duodenum;  not  only  is  it  in  close  relation  with 
other  structures  of  the  greatest  importance  (superior  mesenteric 
vessels,  portal  vein,  pancreas,  etc.),  but  it  also  is  quite  firmly  fixed  on 
account  of  its  retro-peritoneal  position.  Wounds  of  the  duodenum, 
therefore,  are  more  frequently  complicated,  as  well  as  more  difficult 
to  treat,  than  are  those  of  the  jejunum  or  the  ileum. 

(A)  Stab-wounds  of  the  duodenum,  unaccompanied  by  more 
serious  lesions,  do  not  appear  to  have  been  observed.  It  is  of  course 
conceivable  that  such  an  isolated  wound  might  occur,  either  through 
the  loin,  or  from  in  front,  grazing  the  liver  and  the  colon,  or  even  by 
passing  through  the  gastro-colic  omentum,  and  reaching  the  transverse 
duodenum. 

(B)  Gunshot  wounds  of  the  duodenum,  unaccompanied  by  more 
serious  injuries,  have  been  observed  in  several  instances.  According 
to  Cackovic  (1903).  a  gunshot  wound  of  the  duodenum  was  first  sutured 
by  Ramsay,  in  1885.  Harte  (1902)  reported  a  patient  with  a  "grooved  " 
wound  of  the  first  portion  of  the  duodenum,  and  perinephric  hemor- 
rhage, who  recovered  after  suture  of  the  perforation  of  the  duodenum  by 
laparotomy,  and  arrest  of  the  hemorrhage  by  packing  the  kidney- 
region  through  the  loin.  Summers  (1904)  operated  on  a  patient  who 
had  been  shot  in  the  right  loin.  A  double  perforation  of  the  duodenum 
was  found,  also  a  perforation  of  the  gall  bladder.  The  latter  injury, 
and  the  anterior  perforation  of  the  duodenum  were  repaired,  by  su- 
tures, by  laparotomy;  and  the  posterior  (retro-peritoneal)  perfora- 
tion of  the  duodenum,  and  a  wound  of  the  kidney,  were  tamponned 
through  a  lumbar  incision.  Death  occurred  in  three  days  from  "retro- 
peritoneal phlegmon,"  not  from  peritonitis. 

The  treatment  of  gunshot  wounds  of  the  duodenum  is  difficult  be- 
cause of  their  deep  situation,  and  the  frequency  with  which  retro- 
peritoneal injuries  are  overlooked.  Modern  experience  with  mobiliza- 
tion of  the  duodenum  will  render  access  to  retro-peritoneal  lesions  of  its 
descending  portion  less  difficult  than  heretofore.  But  the  uncertainty 
which  always  exists  as  to  the  efficiency  of  closure  of  retro-peritoneal 
portions  of  the  intestine,  makes  the  prognosis  in  such  cases  particu- 
larly grave.     It  usualh'  will  be  well  to  drain  the  sutured  area,  particu- 


INJURIES    OF    THE   DUODENUM  307 

larly  if  it  be  retro-peritoneal.  Drainage  should  always  be  employed, 
preferably  through  the  loin,  if  a  retro-peritoneal  perforation  is  sus- 
pected but  not  definitely  located;  or  if  one  is  located  in  an  inaccessible 
place.  Resection,  with  end-to-end  anastomosis  may  sometimes  be 
required.  In  many  instances  it  probably  will  be  safer  to  close  both 
ends  of  the  duodenum,  and  restore  the  continuity  of  the  intestinal 
canal  by  some  form  or  forms  of  lateral  anastomosis,  as  in  the  case  of 
Meerwein  to  be  cjuoted  below. 

(C)  Rupture  of  the  Duodenum. — Because  of  its  fixed  position 
against  the  spinal  column,  rupture  of  the  duodenum  is  by  no  means  so 
unusual  as  might  be  supposed.  Meerwein  (1Q07)  collected  64  cases; 
and  he  referred  to  iS  others  included  in  the  tables  previously  pubhshed 
by  Jeannel,  the  original  references  to  which  were  not  accessible  to  him. 
According  to  Cackovic  (1903),  operation  for  rupture  of  the  duodenum 
was  first  done  in  i8q6  by  Herczel.  To  show  the  relative  frequency 
with  which  the  duodenum  is  ruptured,  the  following  figures  are  quoted 
from  Gage  (1902):  Duodenum,  10  cases;  jejunum,  20  cases;  ileum, 
42  cases;  colon,  6  cases.  Meerwein  studied  the  records  of  28  operations 
for  this  condition:  16  patients  recovered,  and  12  died,  a  mortality  of 
42.85  per  cent.  But  in  6  of  the  fatal  cases  the  rupture  in  the  duodenum 
was  not  found;  so  that  the  mortality  attending  the  completed  operations 
is  only  27.27  per  cent.  Of  the  six  fatal  cases  in  which  the  rupture  was 
found  at  the  time  of  operation,  three  patients  died  at  once,  two  died 
later  from  peritonitis,  and  one  patient  (Moynihan's)  Hved  in  excel- 
lent health  for  104  days  after  the  operation,  and  died  then  from  perfor- 
ation of  the  intestine  by  the  Murphy  button  which  had  been  employed 
at  the  operation.  Sherwood  (1906)  has  recorded  a  case  of  rupture  of  the 
duodenum,  which  is  not  included  in  Meerwein's  statistics.  This  patient 
died  seven  days  after  suture  of  the  rupture,  from  gangrene  of  the  injured 
bowel.  We  have  references  to  reports  of  27  operations  for  rupture  of 
the  duodenum,  published  since  the  first  edition  of  this  work;  18  of  the 
patients  died,  a  mortality  of  66.6  per  cent.  But  if  6  cases  in  which  the 
rupture  was  not  found,  and  all  terminating  fatally,  are  omitted,  the  mor- 
tality is  reduced  to  57.1  per  cent.,  which  probably  is  nearer  the  truth 
than  the  mortality  recorded  in  the  series  of  cases  collected  by  Meerwein. 

The  transverse  is  more  often  affected  than  the  descending  portion 
of  the  duodenum,  and  the  rupture  usually  occurs  more  or  less  trans- 
versely to  the  long  axis  of  the  intestinal  canal.  The  bowel  may  be 
completely  torn  across.  This  is  not  unusual  at  or  near  the  duodeno- 
jejunal juncture,  as  in  Moynihan's  case;  the  explanation  probably 
being  that  the  greatest  strain  is  felt  where  the  fixed  portion  ceases  and 


3o8  INJURIES    OF   DI.\PHRAGM,    STOMACH   AND    DUODENUM 

the  movable  portion  of  the  bowel  commences.  The  causes  are  blows 
(especially  kicks  from  horses),  falls  and  crushes.  Perry  and  Shaw 
(1893)  refer  to  a  case  of  rupture  of  the  duodenum  produced  by  vomiting; 
ruptures  of  the  stomach  existed  in  the  same  patient;  none  of  the 
lesions  were  discovered  during  life. 

Suture  should  be  done  where  this  is  possible.  If  doubt  exist  as  to 
the  viabiHty  of  the  injured  gut,  excision  had  best  be  done,  difficult  as 
such  an  operation  is.  Sometimes  end-to-end  anastomosis  is  possible. 
In  Moynihan's  patient,  referred  to  above,  a  boy  of  6  years,  a  few 
inches  of  damaged  gut  were  resected,  the  proximal  end  of  the  duo- 
denum was  closed,  and  the  distal  end  (origin  of  the  jejunum)  was 
united  to  the  stomach;  as  a  result  the  whole  of  the  bile  and  pan- 
creatic juice  passed  into  the  stomach  in  order  to  reach  the  jejunum. 
As  already  mentioned,  this  patient  survived  in  excellent  health  for 
104  days,  and  died  then  from  perforation  of  the  bowel  by  the  Murphy 
button  which  had  been  used  in  making  the  anastomosis.  Meerwein 
found  in  his  patient  a  complete  transverse  rupture  of  the  duodenum 
where  it  crossed  the  spinal  column.  It  was  impossible  to  close  the 
rupture  by  an  end-to-end  anastomosis.  Accordingly  the  proximal 
end  was  closed  by  a  purse-string  suture;  the  distal  end  was  then  drawn 
out  from  beneath  the  root  of  the  mesentery  to  the  patient's  left,  the 
de\"italized  portion  of  the  gut  was  excised,  and  the  remaining  (distal) 
end  of  the  duodenum  closed.  A  lateral  anastomosis  was  then  made 
between  the  posterior  wall  of  the  stomach  and  the  upper  jejunum 
(trans-mesocoUc  posterior  gastro-jejunostomy) ;  and  finally  a  lateral 
anastomosis  was  made  between  the  juxta-pyloric  portion  of  the  duo- 
denum and  the  jejunum  about  60  cm.  (24  inches)  from  the  origin  of 
the  latter  (anterior  ante-colic  duodeno-jejunostomy).  As  a  precaution 
gauze  drains  were  left  to  all  the  sutured  areas.  The  patient  recovered. 
Foreign  Bodies  in  the  Duodenum. — At  least  one  instance  (English, 
1905)  of  perforation  of  the  duodenum  by  a  foreign  body  is  on  record;  the 
patient  was  saved  by  operation.  In  a  case  recorded  by  Lucas  (1901), 
a  nail  which,  as  shown  by  skiagraphs,  had  been  lodged  for  some  weeks 
in  the  descending  duodenum  was  successfully  removed  by  duodenotomy. 
Chaput  (1907),  Dehmel  (1910),  Batavyai  (1913),  and  Buchanan  (1913), 
have  also  removed  foreign  bodies  from  the  duodenum.  Crossan  (1916) 
has  recorded  the  history  of  a  patient  under  the  care  of  the  junor  author, 
from  whom  a  fish  bone  (lying  partly  in  the  duodenum  and  partly  in 
the  left  lobe  of  the  liver)  was  removed  at  operation  from  the  gastro- 
hepatic  omentum.  The  patient  died  from  suppurati\'e  hepatitis  which 
had  developed  before  operation. 


CHAPTER  XIV 

TECHNIQUE  OF  OPERATIONS  ON  THE  STOMACH  AND 

DUODENUM 

Preparation  for  Operation. — Whenever  practicable,  it  is  well 
for  the  patient  to  pass  a  night  or  two  in  the  hospital  before  the  day- 
set  for  operation.  In  cases  of  perforation  or  of  hemorrhage,  if  the 
surgeon  think  it  proper  to  operate  for  the  latter  as  an  acute  con- 
dition, there  is  of  course  no  time  for  delay.  When  feasbile,  from  24 
to  48  hours  should  be  devoted  to  putting  the  gastro-intestinal  tract  in 
as  good  a  condition  for  operation  as  possible.  For  at  least  twenty- 
four  hours  before  operation  only  cooked,  and  therefore  sterile,  food 
should  be  given  the  patient.  The  mouth  and  teeth  should  be  thor- 
oughly cleansed  after  each  meal  and  at  bed-time  with  an  astringent, 
alkaline,  and  mildly  antiseptic  wash.  The  mouth  should  be  kept 
as  free  as  possible  from  any  particles  of  food  which  may  undergo  fer- 
mentation. 

A  brisk  purge  should  be  administered  the  day  before  operation, 
preferably  in  the  morning.  Usually  either  Epsom  salts  or  castor  oil 
should  be  chosen,  but  the  preference  of  the  patient  may  be  consulted. 
If  given  in  the  morning  of  the  day  before  operation,  the  effect  of  the 
purge  will  wear  off  during  the  day,  thus  allowing  the  patient  to  have 
an  undisturbed  night  preceding  the  operation.  On  the  morning  of  the 
day  of  operation,  an  enema  should  be  given  to  empty  the  lower  bowel. 

After  the  purge  has  acted,  very  little  food  should  be  given  the 
patient.  If  any  be  given,  it  should  consist  entirely  of  such  material 
as  will  be  readily  absorbed  and  will  leave  little  if  any  residue  in  the 
intestinal  tract. 

The  patient  may  drink  freely  of  sterile  water  until  within  a  few 
hours  of  the  operation.  The  stomach  should  be  empty  at  the  time 
of  operation,  but  it  is  only  in  exceptional  cases  that  it  must  be  emptied 
by  means  of  the  stomach  tube.  Where  there  is  marked  stasis,  espe- 
cially if  there  are  putrefactive  changes  in  the  stomach,  it  is  always 
advisable  to  empty  the  organ  immediately  before  operation. 

Preparation  of  the  Abdomen, — In  the  afternoon  before  the  opera- 
tion, the  abdomen  is  thoroughly  washed  with  green  soap  and  water, 
special  attention  being  paid  to  the  navel.     The  entire  abdomen  is 

309 


3IO   TECHNIQUE  OF  OPERATIONS   ON  THE  STOMACH  AND  DUODENUM 

shaved  and  again  washed  with  the  green  soap  and  water,  gauze  being 
used  instead  of  a  brush.  It  is  then  rinsed  with  sterile  water,  rubbed 
with  60  per  cent,  alcohol,  and,  when  thoroughly  dry,  is  covered  with 
a  sterile  towel,  held  in  place  by  a  few  turns  of  bandage,  or  a  binder. 
Heavy  dressings  are  avoided,  particularly  in  hot  weather,  as  it  is 
undesirable  to  cause  sweating  of  the  underlying  skin.  This  sterile 
towel  is  removed  after  the  patient  has  been  placed  on  the  operating 
table,  after  anesthetization.  The  field  of  operation  is  then  painted 
with  an  alcoholic  solution  of  iodin  (3  per  cent.),  or  of  picric  acid  (2 
per  cent.).  It  is  important  in  using  these  solutions  that  the  skin 
shall  not  have  been  wet  for  several  hours  and  that  the  skin  shall 
not  be  covered  with  sheets,  etc.,  after  it  has  been  painted  with  these 
solutions  until  they  have  thoroughly  dried.  Neglect  of  these  pre- 
cautions may  cause  irritation  or  even  blistering  of  the  skin.  More- 
over, it  is  important  to  be  sure  that  the  solutions  employed  are  not  of 
greater  strength  than  indicated:  if  the  receptacles  in  which  they  are 
contained  are  left  long  uncovered,  the  strength  will  be  increased 
imperceptibly  b}-  evaporation  of  the  alcohol. 

General  Considerations  on  Operative  Technique.  Anesthetic. — 
All  these  patients  deserve  the  services  of  a  professional  anesthetist. 
Ether  is  used  unless  contraindicated,  the  so-called  "open,  drop- 
method"  invariably  being  used.  Ethyl  chloride  is  never  used;  it  is 
seductive  but  dangerous.  In  all  seriously  ill  or  cachetic  patients 
nitrous-oxide-and-oxygen  anesthesia  is  preferred  to  etherization,  as 
taxing  the  excretory  organs  less,  and  minimizing  the  risk  of  post- 
operative pneumonia.  A  hypodermic  injection  of  morphin  (o.oio 
gramme)  and  atropin  (0.0005  gramme)  should  be  given  about  an  hour 
before  beginning  the  anesthetic.  The  patient  is  placed  upon  the  operat- 
ing table  in  the  etherizing  room,  before  anesthesia  is  begun.  We  believe 
that  this  method  reduces  the  amount  of  anesthetic  administered,  ensures 
the  patient  lying  on  the  table  in  as  nearly  normal  an  attitude  as  pos- 
sible, and  thus  is  advantageous  in  every  respect.  Neglect  to  support 
the  normal  arch  of  the  lumbar  spine  by  a  small  pillow  is  a  frequent 
cause  of  post-operative  back-ache.  Ether  is  discontinued  as  soon 
as  possible,  and  occasionally  oxygen  is  administered  as  the  ab- 
dominal wound  is  being  sutured  so  that  consciousness  begins  to 
return  as  the  dressing  is  applied.  Care  is  exercised  to  maintain  bodily 
warmth  during  the  operation,  and  in  the  case  of  very  weak  patients 
the  table  is  covered  with  a  hot  water  bed;  and  the  patient  should 
wear  a  cotton  jacket  and  have  the  legs  and  arms  bandaged  in  the 
same  material,  or  should  wear  long  stockings  of  canton  flannel.     When 


INSTRUMENTS  311 

the  patient  is  transferred  to  bed,  if  he  is  perspiring  freely,  the  clothing 
should  be  changed. 

Assistants.  —  One  assistant  helps  the  surgeon  during  the  operation. 
One  nurse  threads  needles,  hands  instruments,  etc.;  another  is  in 
charge  of  the  gauze  sponges  and  hands  them  to  the  surgeon  as  required; 
while  a  thiid  changes  the  saline  solutions,  keeping  them  constantly 
clean  and  hot ;  and  a  fourth  also  keeps  account  of  all  pieces  of  gauze  used, 
reporting  from  time  to  time  to  the  nurse  in  charge  of  the  gauze,  who 
is  responsible  for  the  final  reckoning  of  pieces  of  gauze  employed  dur- 
ing the  operation.  The  surgeon  does  all  the  operating  himself;  the 
assistant  holds  retractors,  and  so  disposes  the  operative  field  as  to 
make  operating  easy. 

Instruments.^Very  few  special  instruments  are  required.  Good 
retractors  are  a  necessity.  Rubber-covered  clamps  are  extremely 
desirable.  Mechanical  aids  for  gastro-intestinal  anastomosis,  such 
as  the  Murphy  button,  are  never  used  except  in  emergencies,  where 
it  is  desirable  to  terminate  the  operation  rapidly,  or  in  positions 
where  the  application  of  sutures  is  particularly  difiicult.  Thus  in 
doing  anterior  gastro-jejunostomy,  which  is  reserved  for  patients 
with  gastric  cancer  so  far  advanced  as  to  make  even  a  posterior  pal- 
liative operation  imposible,  the  Murphy  button  sometimes  is  used, 
so  as  to  keep  the  abdomen  open  the  very  shortest  possible  time. 
Gauze  packs  are  absolutely  requisite  to  protect  the  general  peritoneal 
cavity,  to  keep  other  abdominal  viscera  from  prolapsing  into  the 
wound,  and  to  maintain  the  vital  heat  of  those  structures  which  are 
exposed.  These  packs  are  about  ten  inches  square,  and  are  made 
by  basting  together  six  to  eight  layers  of  gauze.  They  are  wrung  out 
of  hot  saline  solution  as  required,  and  are  handed  to  the  surgeon  hot. 
It  is  convenient  to  have  a  tape  about  lo  cm.  long  sewed  to  one  corner 
of  the  pack;  this  tape  is  left  protruding  from  the  wound  and  is  clamped 
by  a  hemostat.  If  no  pack  is  ever  put  entirely  inside  the  wound 
none  will  be  lost  inside  the  abdomen. 

Sutures. — Two  main  types  of  sutures  are  used — the  Albert 
(through-and-through)  and  the  Lembert  (sero-serous) ,  as  shown  dia- 
grammatically  in  Fig.  74.  The  Albert  suture  is  invariably  of  absorb- 
able material;  chromicized  or  iodized  catgut  is  employed.  This  suture 
seldom  is  used  in  abdominal  surgery  except  in  the  performance  of 
anastomoses.  It  is  designed  to  be  hemostatic,  and  should  stay  in  the 
tissues  long  enough  not  only  to  make  the  anastomosis  secure  against 
secondary  hemorrhage,  but  to  procure  firm  union  between  the  margins 
of  the  stomach  or  intestine  involved.     It  should  not,  however,  be  of 


312    TECHNIQUE   OF  OPERATIONS  ON  THE   STOMACH  AND  DUODENUM 

non-absorbable  material,  since  then  it  may  ulcerate  out  at  one  place 
and  by  hanging  as  a  loop  in  the  lumen  of  the  newly  formed  channel 
(Fig.  35)  possibly  be  the  cause  of  obstruction.  Or  the  portions  of 
the  suture  still  embedded  in  the  tissues  may  be  torn  out  by  the  drag 
of  the  loop  which  has  ulcerated  out,  and  secondary  hemorrhage  may 


Fig.  74-- 


-Diagram  of  the  Albert  (Through-and-through)    and  the  Lambert  (Sero-serous) 

Sutures. 


be  started  or  a  marginal  ulcer  formed.  These  through-and-through 
sutures  are  always  used  as  a  continuous  suture;  if  there  should  be 
danger  of  the  suture  puckering  the  anastomosis,  this  ma}'  easily  be 
prevented  by  arresting  the  suture  by  a  knot  at  three  or  four  points  as 


Fig.  75-- 


-Interrupted  Sero-serous  Suture. 
(Lembert's  Suture.) 


Fig.    76. —  Begmnini;   iiie    i^onimunus  Sero- 
serous  Suture.     (Dupuytren's  Suture.) 


it  passes  around  the  circumference  of  the  anastomosis  or  by  taking  a 
back-stitch  one  in  every  eight  to  ten  stitches. 

Sero-serous  Sutures. — Various  forms  of  this  general  type  are 
shown  in  the  accompanying  illustrations.  Linen  thread  is  used  in  all 
cases,  and  the  needle  picks  up  all  the  coats  but  the  mucous,     i.  In- 


INTESTINAL   SUTURE 


313 


terrupted  Lembert  Suture  (Fig.  75)  is  especially  applicable  for  reinforc- 
ing a  continuous  Lembert  suture  at  any  point  where  it  appears  likely 
to  leak.     2.  Continuous  Lembert  Suture,  known  also  as  Dupuytren's 


Pig.  77. — Subsequent  Steps  of  the  Contin- 
uous Sero-serous  Suture  of  Dupuytren. 


Fig.   78. — Fixing  the  End  of  the  Contin- 
uous Sero-serous  Suture  by  a  Knot. 


Suture  (Fig.  78),  is  that  which  is  most  often  used  in  all  forms  of 
intestinal  surgery.  The  suture  is  commenced  by  catching  up  on  the 
needle  a  bite  of  the  serous,  muscular,  and  submucous  coat  on  each  side 


ff-m- 


Fig.   79. — Commencing  a  New  Continuous       Pig.  8o. — Interrupted  Sero-serous  Suture 
Sero-serous  Suture  by  Tying  It  to  the  End  of  of  the  Mattress  Type, 

the  Previous  Stitch. 

of  and  a  little  beyond  the  end  of  the  intestinal  wound,  the  needle  being 
held  at  right  angles  to  the  wound.  The  suture  is  fixed  at  its  starting 
point  by  tying  a  square  knot  (Fig.  76).     The  needle  then  again  picks 


Fig.  81. — Continuous  Sero-serous  Suture       Pig.  82. — Continuous  Right-angled  Sero-serous 
of  Mattress  Type.  Suture  of  Heyward  Gushing. 

up  all  the  coats  but  the  mucous  on  each  side  of  the  wound,  crossing 
back  to  the  original  side  of  the  wound  before  commencing  each  new 
stitch  (Fig.  77),  and  thus  continues  until  the  other  end  of  the  wound 


314   TECHNIQUE   OF  OPERATIONS   ON  THE  STOM.A.CH   AND   DVODENUM 


is  reached,  where  the  thread  is  knotted  as  shown  in  Fig.  78.  Should 
the  suture  be  too  short  to  reach  the  entire  length  of  the  wound,  or 
should  it  fortunately  break,  it  may  be  knotted  at  any  point,  and 
a  new  suture  started  (Fig.  79).  3.  Interrupted  :\Iattress  Suture 
(Fig.  So) :  this  is  particularly  adapted  for  places  where  the  intestine 
is  friable,  or  where  there  is  much  tension  on  the  sutures.  4.  Con- 
tinuous Mattress  Suture  is  shown  in  Fig.  81.     5.  Right-angled  Suture 

(Fig.  82),  in  which  the  needle  is 
inserted  parallel  to  the  edges  of 
the  intestinal  wound,  secures  ex- 
cellent appro.ximation,  and  is  often 
preferable  to  the  continuous  mat- 
tress suture,  because  it  can  be 
applied  so  much  more  quickly. 

Closure  of  the  Abdominal 
Wound. — The  peritoneum  is  su- 
tured by  a  continuous  catgut 
suture,  in  such  a  way  that  the 
serous  surfaces  are  everted  into 
the  wound,  thus  bringing  serosa 
against  serosa,  ensuring  rapid 
union,  and  leaving  no  projections 
within  the  abdomen  to  favor 
adhesions  between  the  scar  and 
omentum  or  other  abdominal 
viscera  (Fig.  83).  This  suture 
Fig.  83.— Closing  the  ParietaiiPeritoneum  should  begin  and  end  beyond  the 
2'aB°:tT::L^sTiL':s  ^Z^r-  extremities  of  the  peritoneal  wound. 

Two  or  three  "splint  sutures"  of 
silkworm  gut  are  then  introduced  from  the  skin  surface  of  one 
side  through  all  structures  but  the  peritoneum  and  out  again 
through  the  other  side  of  the  wound  (Fig.  84).  If  the  abdominal 
incision  is  very  short,  it  is  not  necessary  to  use  these  splint  sutures; 
but  in  any  wound  of  more  than  8  cm.  it  is  safer  to  employ  them. 
They  act  not  only  as  tension  sutures,  relieving  the  strain  on  the  buried 
(absorbable)  sutures,  but  they  also  obliterate  all  dead  spaces  between 
the  different  layers  of  the  abdominal  wall,  thus  preventing  the  for- 
mation of  hematomata  and  subsequent  infection.  When  these  splint 
sutures  have  all  been  placed,  but  before  they  are  tied,  the  peritoneal 
suture  first  employed  is  continued  downward,  as  shown  in  Fig.  85, 
uniting  the  anterior  sheath  of  the  rectus,  and  is  finally  tied  to  its  own 


CLOSING    THE    ABDOMINAL    WOUND 


315 


Fig.  84. — Method  of  Inserting  the  "Splint  Sutures"  of  Silkworm  Gut. 


Fig  85. — Suture  ot  the  Sheath  of  the  Rectus  Muscle. 


3l6    TECHNIQUE   OF  OPERATIONS   ON   THE   STOMACH  AND  DUODENUM 


initial  extremity  (A  to  B).  Finally  the  splint  sutures  are  tied 
(Fig.  86).  In  suturing  an  incision  in  a  very  obese  patient,  it 
is  not  desirable  to  close  the  skin  surface  too  tightly.  It  is  safer  to 
leave  space  between  the  sutures  for  drainage  of  the  fat  necrosis. 

After-treatment. — The  motto  for  Ward  Surgeons  is  "Let  the 
patient  get  well."  Very  little  after-treatment  except  careful  nursing 
is  required.  A  Htre  of  tap  water,  at  a  temperature  of  105°  to  110°  F., 
given  by  enema  before  complete  recovery  from  the  anesthetic  is  readily 

retained ;  and  serves  to  prevent  distressing 
thirst,  to  stimulate  excretion  by  the  kid- 
neys, and  renders  very  rare  the  occur- 
rence of  retention  of  urine.  The  patients 
are  raised  up  in  bed  as  soon  as  the  effects 
of  the  ether  pass  away;  or  the  head  of  the 
bed  may  be  raised  about  1 5  degrees  from 
the  horizontal.  Vomiting  is  unusual;  it 
is  treated  by  total  abstinence  from  mouth 
feeding;  by  sitting  the  patient  up  in  bed; 
by  the  administration  of  a  glass  of  hot 
water  and  finally  by  lavage.  The  patients 
do  not  have  much  pain.  If  they  do  suffer 
from  pain,  the  ward  surgeon,  after  con- 
sultation with  the  chief,  is  authorized  to 
administer  a  hypodermic  injection  of 
morphin  (o.oio  gramme)  and  repeat  if 
necessary.  But  a  minimum  quantity 
of  ether,  speedy  and  orderly  operating, 
render  the  subsequent  use  of  morphin  exceptional.  Water  (at  first 
sips  of  hot  water),  or  small  pieces  of  ice  may  be  given  after  12 
hours  if  there  is  no  nausea.  Feeding — liquid  diet —  is  not  begun  for 
from  48  to  72  hours  after  operation:  at  first  albumin  water,  buttermilk, 
broths,  etc.,  are  allowed;  but  not  until  flatus  is  passed  or  auscultation 
detects  normal  peristalsis,  is  soft  diet  given.  At  the  end  of  ten  days 
or  two  weeks  the  patients  are  allowed  to  get  up;  but  they  should  not 
be  hurried  out  of  the  hospital  before  their  wounds  are  entirely  healed, 
nor  until  they  are  able  to  take  care  of  themselves. 


Fig.  86. — Tying  the  Splint  Sutures. 


Gastrotomy 
I.  For  the  removal  of  foreign  bodies  from  the  stom- 


Indications. 

ach,  or  from  the  lower  end  of  the  esophagus. 


GASTROTOMY  317 

2.  As  a  preliminary  to  the  dilatation  of  stricture  of  the  pylorus, 
the  cardia  or  the  esophagus. 

3.  For  the  control  of  hemorrhage  within  the  stomach. 

4.  For  the  removal  of  polypi  or  other  pedunculated  tumors  from 
the  interior  of  the  stomach. 

5.  As  an  incident  in  certain  operations  on  the  posterior  wall  of  the 
stomach. 

Incision. — This  is  to  be  made  through  the  left  rectus  muscle  close 
to  the  median  line,  from  the  tip  of  the  ensiform  process  downward  for 
8  to  10  cm. 

Exploration. — Locate  the  left  lobe  of  the  liver;  immediately  be- 
neath this  is  the  stomach.  While  the  assistant  raises  the  margins  of 
the  abdominal  incision  with  retractors,  inspect  the  anterior  gastric  wall. 
If  the  colon  bulges  into  the  wound,  pack  in  gauze  pads  until  it  stays 
out  of  the  operative  field.  If  the  operation  is  for  the  removal  of  a 
foreign  body,  palpate  the  stomach  gently,  and  try  to  locate  the  body 
to  be  extracted.  When  the  foreign  body  has  been  fixed  with  the 
fingers  in  contact  with  the  anterior  gastric  wall,  other  gauze  pads 
should  be  introduced  so  as  to  isolate  completely  the  portion  of  the 
stomach  wall  to  be  opened.  The  stomach  may  be  grasped  with 
rat-tooth  or  Allis  forceps,  to  facilitate  this  part  of  the  operation. 

Opening  the  Stomach. — When  the  stomach  has  been  isolated  thus 
a  small  incision  may  be  made  in  its  anterior  wall  with  a  scalpel.  If 
the  object  is  to  remove  a  foreign  body,  no  longer  an  incision  should 
be  made  than  is  absolutely  necessary  to  extract  the  foreign  body;  and 
under  these  circumstances  the  incision  is  best  made  transverse  to  the 
long  axis  of  the  stomach,  parallel  with  the  gastric  blood  vessels.  If, 
however,  the  stomach  must  be  more  widely  opened,  as  for  exploration 
of  the  esophagus  or  the  removal  of  an  endogastric  polyp,  the  incision 
in  its  wall  is  best  made  longitudinally,  and  any  bleeding  points  should 
be  caught  In  hemostatic  forceps,  which  will  then  serve  the  useful  pur- 
pose of  retractors.  For  exploring  the  esophagus  the  incision  should 
be  made  beneath  the  cardiac  orifice,  while  if  the  pylorus  is  to  be  dilated, 
or  a  pyloric  polyp  removed,  the  surgeon  will  naturally  place  his  incision 
nearer  to  it.  In  exploring  the  esophagus  it  is  well  to  bear  in  mind  that 
the  lower  end  of  the  esophagus  turns  toward  the  patient's  left,  and  that 
the  cardiac  is  frequently  more  or  less  obscured  by  a  fold  of  mucous 
membrane.  Nine  times  out  of  ten  the  inexperienced  operator  will 
vainly  endeavor  to  poke  a  hole  through  the  fundus  of  the  stomach, 
pointing  his  finger  to  the  patient's  head,  instead  of  obhquely  to  his 
right. 


3l8    TECHNIQUE   OF  OPERATIONS  ON   THE   STOMACH  AND  DUODENUM 

Closing  the  Stomach. — When  the  endogastric  manipulations 
have  been  concluded,  the  stomach  wall  is  to  be  sutured  with  at  least 
two  layers  or  sutures  (Albert-Lembert).  The  stomach  is  then  al- 
lowed to  fall  back  into  the  abdomen;  the  gauze  packs  are  removed; 
and  the  abdominal  wound  closed  in  the  usual  way  without  drainage. 

Gastrostomy 

Indications. — i.  Impermeable  stricture  of  the  esophagus,  or  malig- 
nant obstruction  of  the  cardiac  orifice  of  the  stomach. 

2.  A  modified  form  of  gastrostomy  may  be  necessary  in  cases  of 
phlegmonous  gastritis. 

The  operation  of  gastrostomy,  according  to  Sencert  (1905),  was  first 
suggested  as  a  remedy  for  stricture  of  the  esophagus  by  Engelbert,  a 
Norwegian,  in  1837.  It  was  first  performed  in  1849,  by  Sedillot,  of 
Strasbourg.  In  most  cases  in  which  it  is  adopted  it  is  desirable  to 
estabhsh  a  more  or  less  permanent  opening  for  the  purpose  of  intro- 
ducing food  into  the  stomach.  But  in  addition  to  the  permanency  of 
the  fistula,  it  is  extremely  desirable  to  have  a  continent  opening,  one 
which  will  not  leak;  for  leakage  will  not  only  deprive  the  patient  of  the 
benefit  of  the  food  which  has  been  introduced,  but  will  keep  his  cloth- 
ing constantly  wet  between  feedings,  by  allowing  the  escape  of  the 
gastric  juice.  A  third  desideratum,  much  less  important,  however, 
than  those  just  mentioned,  is  that  the  fistula  shall  close  spontaneously 
when  it  is  no  longer  needed. 

Among  the  many  methods  which  have  been  devised  for  the  per- 
formance of  gastrostomy,  it  is  our  intention  to  describe  only  the  follow- 
ing: I.  The  methods  of  Witzel,  of  Stamm.  and  of  Kader,  all  of  which 
are  based  on  the  principle  of  inverting  the  gastric  wall  so  as  to  form  a 
funnel-hke  channel  from  the  ca^^ty  of  the  stomach  to  the  wall  of  the 
abdomen.  2.  The  method  of  Tavel,  in  which  a  segment  of  the  jejunum 
is  used  as  the  fistulous  tract  between  the  stomach  and  the  skin.  3.  The 
methods  of  Roux,  Herzen,  Jianu  and  Willy  Meyer,  in  which  an  attempt 
is  made  to  construct  a  new  subcutaneous  esophagus,  in  front  of  the 
sternum,  by  transplantation  of  portions  of  the  jejunum  or  stomach 
itself. 

I.  Methods  of  Witzel,  Stamm,  and  Kader.  Incision. — The  incision 
is  made  through  the  middle  of  the  left  rectus  muscle,  from  a  little  below; 
the  costal  margin  downward  for  about  7.5  cm.  In  very  young  children 
the  large  size  of  the  liver  makes  a  lower  incision  preferable.  If  the 
interior  of  the  stomach  is  to  be  explored,  as  in  cases  of  stricture  of  the 


WITZEL  S   GASTROSTOMY 


319 


esophagus,  or  for  other  reason,  the  operation  of  gastrotomy,  as  described 
at  page  317,  will  first  be  performed;  and  then  the  incision  in  the  an- 
terior gastric  wall  should  be  closed  except  at  one  end,  where  an  opening 
should  be  left  just  large  enough  to  admit  a  large  rubber  catheter  (Nos. 
26  to  30  French)  or  drainage  tube.  The  gastrostomy  opening  should 
be  made  about  midway  between  the  greater  and  lesser  curvatures,  and 
in  the  pyloric  portion  of  the  stomach  for  the  same  reasons  that  make 
one  Select  this  portion  of  the  stomach  (when  available)  for  gastro- 
jejunostomy, namely  its  thicker  walls,  and  its  function  as  part  of  the 
canalis  gastricus. 


Fig.  87. — Witzel's  Gastrostomy.     Sutur- 
ing the  Catheter  in  Place. 


Fig.   88. — Witzel's    Gastrostomy.     Closure 
of  the  Abdominal  Wound. 


(a)  Witzel's  Method  (1891). — The  catheter  is  laid  on  the  anterior 
wall  of  the  stomach  with  its  gastric  end  toward  the  lesser  curvature,  and 
the  stomach  wall  is  then  sutured  over  it  by  a  row  of  sero-serous  sutures 
(interrupted).  When  the  catheter  is  thus  fixed  in  a  serous  channel,  a 
small  opening  is  made  in  the  gastric  wall  at  the  extremity  of  the  infolded 
area,  the  gastric  end  of  the  catheter  is  passed  through  this  into  the 
stomach  for  2  or  3  cm.,  and  is  anchored  in  place  by  a  single  catgut 
suture  passing  through  the  catheter  and  through  the  entire  thickness  of 
the  gastric  wall  (Fig.  87).  The  opening  in  the  stomach  wall  is  then 
buried  by  a  few  additional  sutures.  All  these  sutures  should  be  of 
linen,  except  that  used  to  fix  the  catheter  in  the  gastric  opening;  by  using 
plain  catgut  for  this,  the  suture  will  be  absorbed  in  four  or,  five  days, 
when  the  catheter  may  be  removed,  washed,  and  replaced;  since  by  this 
time  the  adhesions  of  the  stomach  to  the  anterior  abdominal  wall  will 
make  the  temporary  removal  of  the  catheter  quite  safe.     The  catheter 


320    TECHNIQUE  OF   OPERATIONS   ON  THE   STOMACH  AND  DUODENUM 

should  be  clamped  at  its  outer  end  to  prevent  leakage  of  gastric  con- 
tents through  it  during  the  remaining  steps  of  the  operation.  The 
stomach  may  now  be  sutured  to  the  parietal  peritoneum  by  three  or  four 
interrupted  linen  sutures,  but  as  a  rule  it  is  unnecessary  to  attach  the 
stomach  to  the  abdominal  wall,  since  by  the  time  the  tube  is  removed 
sufficient  adhesions  will  have  formed  to  prevent  leakage  into  the 
unprotected  peritoneal  cavity.  The  abdominal  wound  is  to  be  closed 
in  the  usual  way  without  drainage,  except  for  such  drainage  as  takes 
place  along  the  tract  of  the  catheter. 

(b)  Stamm's  Method  (1894).' — A  small  incision,  just  large  enough 
to  admit  the  catheter,  is  made  in  the  anterior  gastric  wall;  the  catheter 
(its  outer  end  clamped)  is  inserted  for  about  2  cm.  inside  the  cavity 
of  the  stomach,  and  is  fixed  in  the  gastric  wall  by  a  single  suture  of 
catgut  (Fig.  89).  Then  a  purse-string  suture  of  linen  is  taken  in  the 
stomach  wall,  circularly  around  the  catheter,  and  about  2  cm.  distant 
from  it;  as  this  suture  is  tightened  the  catheter  is  pushed  toward  the 
cavity  of  the  stomach,  carrying  with  it  the  incision  in  the  stomach  wall, 
and  thus  inverting  the  gastric  wall  so  that  the  catheter  lies  in  a  serous 
channel.  One  or  two  other  purse-string  sutures  are  similarly  passed, 
and  as  each  is  tightened  the  inverted  cone  of  gastric  wall  is  lengthened, 
so  that  finally  the  catheter  lies  in  a  channel  of  more  than  3  cm.  in 
length  (Fig.  89,0).  The  abdominal  wound  is  then  closed  in  layers 
around  the  catheter. 

(c)  Kader's  Method. — The  catheter  is  fixed  in  the  gastric  wall  as 
in  the  previous  operation,  and  the  wall  of  the  stomach  is  then  inverted 
by  a  series  of  Lembert  sutures  of  linen  passed  on  opposite  sides  of  the 
catheter;  two  sutures  are  passed  above  the  catheter,  each  picking  up 
the  sero-muscular  coats  of  the  stomach  in  two  places,  so  as  to  form 
two  ridges  with  a  groove  between  them;  two  other  sutures  are  simi- 
larly placed  below  the  tube;  then,  as  this  first  series  (consisting  of 
four  sutures)  is  tightened,  the  catheter  is  pushed  inward,  and,  carry- 
ing the  gastric  wall  with  it,  comes  to  lie  in  a  serous  channel  as  in  the 
operations  previously  described.  Two  or  three  layers  of  these  sutures 
are  necessary  to  invert  enough  of  the  gastric  wall,  each  newly  applied 
series  burying  the  preceding  sutures.  The  abdominal  wound  is 
closed  in  the  usual  way. 

Remarks. — Of   these   three   operations,   Stamm's   method   is   the 
simplest,  and  requires  less  of  the  gastric  wall  for  its  successful  per- 

'  E.  J.  Senn's  operation (1896)  consisted  in  drawing  out  a  cone  shaped  portion  of  tlie 
anterior  gastric  wall,  and  maintaining  it  in  this  form  by  the  application  of  purse-string 
sutures;  the  gastric  listula  was  thus  lined  by  mucous  membrane — just  the  reverse  of 
Stamm's  method. 


STAMM  S    GASTROSTOMY 


321 


formance  than  either  of  the  others.  This  is  an  important  point  when 
the  stomach  is  contracted  from  long  disuse  owing  to  esophageal  or 
cardiac  obstruction.     We  prefer  it  to  all  other  methods,  in  ordinary 


Fig.  89. — Stamm's  Method  of  Gastrostomy:  the  Tube  is  Fixed  to  the  Gastric  Opening 
by  a  Single  Suture  of  Plain  Catgut.  A  Purse-string  Suture  of  Linen  is  then  Applied  and 
Drawn  Taut  (Fig.  A).  A  Second  and  Sometimes  a  Third  Purse-string  is  Inserted  (Fig.  B). 
The  Relation  of  the  Tube  to  the  Inverted  Gastric  Wall  is  Indicated  in  Pig.  C. 

cases.  The  channel  formed  from  the  cavity  of  the  stomach  to  the 
skin  in  all  these  operations  is  usually  absolutely  continent  so  long  as 
the  catheter  is  in  place;  and  unless  the  catheter  remains  in  the  fistula 


322    TECHNIQUE   OF  OPERATIONS   ON   THE   STOMACH  AND  DUODENUM 

for  some  months  after  the  operation  the  channel  is  prone  to  become 
entirely  obhterated  from  adhesion  of  its  serous  surfaces  if  the  catheter 
is  removed  and  not  replaced  for  a  week  or  ten  days.  Continence  during 
the  absence  of  the  catheter  from  the  hstula  usually  improves  some 
months  after  the  operation,  and  as  the  serous  Uning  will  be  pretty 
well  obhterated  by  this  time,  no  fear  of  spontaneous  closure  need  be 
entertained  if  the  catheter  is  left  out  of  the  fistula  between  meal  times. 

2.  Tavel's  Operation  (1906)  has  for  its  object  the  formation  of  a 
continent  gastric  fistula,  lined  by  mucous  membrane.  An  incision  is 
made  through  the  left  rectus  muscle,  about  four  inches  (10  cm.)  in 
length,  and  a  w^ell-nourished  loop  of  the  upper  jejunum  is  selected, 
provided  with  a  long  mesentery.  The  jejunum  is  then  divided  in  two 
places,  about  12  cm.  apart,  both  sides  of  each  section  being  guarded 
by  rubber-covered  clamps.  The  intervening  portion  of  intestine  is 
then  excluded  by  doing  an  end-to-end  anastomosis  of  the  upper  and 
lower  segments.  Either  sutures  or  the  Murphy  button  may  be  used 
for  this  purpose.  The  excluded  segment  is  then  transplanted  through 
the  transverse  mesocolon  into  the  lesser  peritoneal  cavity,  and  through 
the  gastro-coUc  omentum  out  again  into  the  upper  portion  of  the 
general  peritoneal  cavity.  The  anal  end  of  the  excluded  segment 
(which  must  be  carefully  distinguished  from  the  upper  or  duodenal  end) 
is  then  sutured  into  the  anterior  gastric  wall  (end  to  side  implantation), 
and  the  duodenal  end  of  the  gut  is  sutured  into  the  abdominal  wound. 
The  remaining  portion  of  the  abdominal  incision  is  then  closed  in  the 
usual  manner.  The  peristaltic  action  of  the  bowel  thus  tends  toward 
the  stomach,  and  a  continent  fistula  is  estabhshed,  fined  with  mucous 
membrane,  and  therefore  having  no  tendency  to  contract. 

Remarks. — Although  we  have  had  no  personal  experience  with 
this  operation,  having  no  reason  to  be  dissatisfied  with  the  results 
obtained  by  Stamm's  and  by  Witzel's  methods,  the  few  reported  cases 
in  which  Tavel's  method  has  been  adopted  have  done  well,  and  the 
fistula  has  entirely  fulfilled  the  expectations  of  its  inventor.  It  should, 
however,  be  remarked,  that  the  operation  is  in  itself  a  more  serious 
undertaking  than  those  already  discussed,  and  that  the  time  consumed, 
apart  from  the  shock  of  an  intestinal  resection,  will  be  a  decided  con- 
traindication in  the  case  of  many  patients  in  whom  some  form  of 
gastrostomy  must  be  done.  Lambotte  (1908)  is  said  to  have  employed 
Tavel's  operation  successfully  in  two  patients. 

3.  Operations  of  Esophagoplasty.  (a)  Rotix's  Operation. — Ihe 
purpose  of  this  operation  is  to  create  a  new  esophagus  by  transplanting 
a  segment  of  the  jejunum  into  the  subcutaneous  tissue  over  the  star- 


ESOPHAGOPLASTY  323 

num.  and  tinally  joining  its  upper  end  to  the  esophagus  above  the 
stricture,  and  its  lower  end  to  the  stomach.     It  is  interesting  to  trace 
the    development    of    an    operation    seemingly    so    complicated.     In 
1894  Bircher  attempted  in  two  patients  to  create  a  channel,  hned  by 
skin,  over  the  sternum,  by  means  of  a  plastic  operation  on  the  skin, 
with  the  idea  that  this  channel  should  serve  as  an  artificial  esophagus, 
by  being  joined  above  to  the  gullet,  and  below  to  the  stomach.     In 
1904   Wullstein  proposed   an  operation  described  as  "ante-thoracic 
esophago-jejunostomy."     He  worked  out  the  operation  on  the  cadaver 
thus:  he   divided  the  jejunum,  did  an  anastomosis  in-Y,  drew    the 
distal  loop  of  intestine  through  the  transverse  mesocolon  and  the 
gastro-colic  omentum,  and  sutured  it  to  the  skin  of  the  epigastrium. 
The  cervical  esophagus  was  to  be  connectd  with  this  jejunal  fistula  by  a 
rubber  tube.     Six  months  later  Gluck  operated  upon  a  patient,  join- 
ing an  esophageal  cervical  fistula   to  a  gastric  fistula.     Baudouin, 
ignorant  of  others'  work,  proposed  a  similar  operation  in  1907. 
Roux  (1907)  operated  in  the  following  manner: 
Selecting  a  portion  of  jejunum  provided  with  a  long  mesentery, 
he  divided  the  bowel  in  two  places  far  enough  apart  to  allow  of  the 
intervening  portion  reaching  from  the  stomach  to  the  patient's  neck. 
He  then  re-established  the  intestinal  canal  by  means  of  a  Murphy 
button,  and  withdrew  the  excluded  loop  from  the  abdomen  after  de- 
taching only  the  upper  two-thirds  or  so  of  its  mesentery.     Owing  to 
the  anatomical  distribution  of  the  blood  vessels  in  the  upper  jejunum, 
this  is  quite  easily  accomplished.     After  implanting  the  distal  end  of 
the  excluded  jejunal  loop  into  the  anterior  wall  of  the  stomach,  the 
patient  was  fed  through  the  transplanted  jejunum,  before  the  subse- 
quent steps  of  the  operation  were  undertaken.     A  subcutaneous  chan- 
nel was  next  made  from  the  upper  angle  of  the  abdominal  wound  at  the 
ensiform  process  to  the  vpper  sternal  region,  and  the  loop  of  jejunum 
was  carefully  drawn  up  through  this  channel,  and  its  upper  end  sutured 
to  the  skin.     The  arterioles  in  the  gut  thus  transplanted  continued  to 
beat  normally.     A  stomach  tube  was  passed  down  through  the  bowel 
from  the  neck  into  the  stomach,  and  allowed  to  remain  in  place  several 
days,  to  facilitate  feeding  while  the  bowel  acquired  firm  attachments 
in  its  new  situation.     The  progress  of  the  case  was  uneventful.  The 
child  was  ready  to  be  up  when  the  case  was  reported.     Only  a  little 
mucus   was   exuded   from   the   fistula   in   the   neck,   and  no     gastric 
regurgitation  was  ever  observed.     The  operation  as  planned  was  to  be 
concluded  at  a  second  sitting,  in  which  the  esophagus  above  the 
stricture  was  to  be  united  to  the  jejuno-gastric  fistula. 


324   TECHNIQUE  OF  OPERATIONS  ON  THE  STOMACH  AND  DUODENUM 

This  operation  as  devised  by  Roux  had  been  carried  out,  accord- 
ing to  Herzen  (1908),  by  Kocher,  Lambotte,  and  Gramse,  as  well  as 
by  Herzen  himself.  All  these  patients  had  carcinomatous  obstruc- 
tion of  the  cardia  or  esophagus,  and  all  succumbed,  though  Herzen's 
patient  lived  until  the  fourth  day.  Lexer  (1911)  adopted  the  opera- 
tion in  a  case  of  impermeable  stricture  of  the  esophagus,  the  jejunal 
tube  having  been  united  to  the  cervical  esophagus  by  inverting  a 
cylinder  of  skin  over  the  upper  end  of  the  sternum;  his  patient  was 
still  using  the  new  esophagus  with  satisfaction  a  year  after  operation 
and  according  to  a  recent  note  in  the  Centralhlatt  fur  Chirurgie  (1920, 
xlviii,  509)  is  still  living.  Frangenheim  (191 1)  also  reported  a  suc- 
cessful operation  of  this  nature. 

[h)  Herzen,  of  Moskow,  modified  (1908)  this  operation  of  Roux  by 
transplanting  the  excluded  jejunal  loop  through  the  transverse  meso- 
colon and  the  gastro-colic  omentum,  as  in  Wullstein's  operation 
described  above ;  and  by  dividing  the  operation  into  three  stages.  The 
first  step  is  to  do  "Jejunostomia  retro-colica  ante-thoracica  cervicalis 
3'psiliformis,"  much  as  in  Wullstein's  operation.  The  second  stage 
consists  in  dividing  the  transplanted  segment  of  jejunum  above  the 
Y-anastomosis,  closing  the  distal  end,  resecting  any  redundant  portion 
of  the  pro.ximal  loop,  and  implanting  the  anal  end  of  the  proximal  loop 
into  the  stomach.  At  the  third  operation,  the  cervical  esophagus  is 
united  to  the  duodenal  end  of  the  jejunal  loop,  which  was  sutured  to 
the  skin  of  the  cervical  region  at  the  first  operation. 

Herzen  did  the  first  stage  of  his  modification  of  Roux's  operation 
(retro-colic  ante-thoracic  cervical  jejunostomy  in-Y)  on  a  very  weak 
patient  with  cancer,  who  felt  so  much  better  after  being  fed  through 
the  jejunal  fistula  that  he  refused  further  treatment.  The  entire  opera- 
tion, in  three  stages,  was  done  on  another  patient,  on  Sept.  10,  Oct. 
4,  and  Nov.  17,  1907  (the  cervical  esophagus  and  the  transplanted 
jejunum  being  joined  by  end-to-end  anastomosis),  with  entire  success, 
a  small  esophageal  fistula  closing  in  three  weeks,  and  the  patient  being 
in  good  health  four  weeks  later,  when  he  was  shown  to  the  Congress, 
and  easily  swallowed  bread,  meat-hash,  eggs,  etc.  Intestinal  peristal- 
sis was  visible  under  the  skin  of  the  thorax. 

(c)  Jianu,  of  Bucarest,  in  1912,  described  a  similar  method  of 
esophagoplasty,  in  which  a  tube  was  constructed  from  the  greater 
curvature  of  the  stomach  itself,  instead  of  from  the  jejunum.  The 
stomach  is  drawn  forward,  and  the  gastrocolic  omentum  divided 
from  near  the  pylorus  well  up  to  the  fundus  of  the  stomach,  the  line 
of  section  passing  between  the  gastro-epiploic  vessels  and  the  colon. 


ESOPHAGOPLASTY 


325 


Then  the  anterior  and  posterior  walls  of  the  stomach  are  incised  par- 
allel with  the  greater  curvature,  a  long  flap  nourished  by  the  left  gastro- 
epiploic artery  being  raised,  with  attachment  at  the  fundus  (Fig.  90). 
The  stomach  opening  and  the  free  edges  of  the  flap  are  closed  by  suture, 
and  the  tubular  canal  is  brought  out  at  the  upper  end  of  the  abdominal 
incision,  and  carried  up  beneath  the  skin  covering  the  sternum  as  far 
as  it  will  reach.  If  care  has  been  taken  to  moblize  the  fundus  of  the 
stomach  sufficiently  by  division  of  the  gastro-splenic  and  gastro- 
phrenic ligaments,  the  tube  should  reach  almost  to  the  neck.  The 
advantage  of  cutting  the  end  of  the  tube  from  the  pyloric  portion  of 


-r.,! 


Fig.  90. — Diagrams  Representing  the  Steps  in  Jianu's   Method  of    Esophagoplasty. 
Fig.  I  Indicates  the  Incision  in  the  Stoniach  Parallel  to  Its  Greater  Curvature.    Fig.  2 
Shows  the  New  Esophagus  Constructed  from  the  Greater  Curvature.     Fig.  3  Shows  the  • 
New  Esophagus  Rotated  Toward  the  Midline.     Pig.  4  Shows  It  Placed  Subcutaneously 
over  the  Sternum  and  United  with  the  Cervical  Esophagus. 

the  stomach  is  that  the  secretions  of  its  mucous  membrane,  not  being 
acid,  will  not  digest  the  skin  of  the  neck  around  the  opening.  Subse- 
quently an  anastomosis  is  made  with  the  cervical  esophagus  either 
directly,  or  indirectly  by  constructing  a  plastic  skin  channel. 

In  1914  Jianu  described  two  cases  in  which  he  had  employed  this 
operation  successfully  in  children.  W.  Meyer  (1914)  has  used  the 
operation  in  three  cases  with  good  results.  He  thinks  it  important 
to  make  the  orifice  between  tube  and  cavity  of  the  stomach  small,  and 
to  cauterize  the  branches  of  the  pneumogastric  nerves  which  supply 


326    TECHNIQUE   OF   OPERATIONS   ON   THE    STOMACH   AND   DrODENUM 

the  tube,  so  as  to  prevent  regurgitation  from  the  stomach.  Jianu 
says  if  regurgitation  occurs  it  is  due  to  faulty  technique — not  con- 
structing the  base  of  the  tube  high  enough  in  the  fundus  of  the  stomach.^ 
Remarks. — That  the  methods  of  Herzen  and  Jianu  are  improve- 
ments over  that  of  Roux  is  probably  true;  but  the  same  objection  lies 
against  both  that  we  raised  against  Tavel's  method,  namely,  that  in 
most  patients  such  a  severe  operation  will  kill.  If  the  operation  is  to 
be  undertaken  for  the  relief  of  carcinomatous  stenoses  this  fact  may 
not  be  thought  to  be  an  objection;  but  the  surgeon  is  not  an  execu- 
tioner. It  does  seem,  however,  that  such  an  operation  as  this  may 
well  be  of  use  in  cases  of  impermeable  benign  stricture  of  the  esoph- 
agus, which  have  hitherto  baffled  surgeons  completely.  Internal 
esophagotomy  and  retrograde  dilatation  in  some  patients  will  con- 
tinue to  fail  in  the  future  as  they  have  in  the  past  to  relieve  the  de- 
plorable condition  of  those  who  must  feed  themselves  through  a  gastric 
fistula;  and  in  such  patients,  whose  general  health  is  good,  but  in 
whom  no  other  means  of  cure  is  available,  the  operations  of  Roux, 
Herzen  and  Jianu  may  be  perfectly  justifiable. 

Pyloroplasty 

Inasmuch  as  the  inefficiency  of  the  old-fashioned  pyloroplasty 
has  been  abundantly  demonstrated,  it  is  our  intention  to  describe 
only  Finney's  modification.  Although  Finney  still  prefers  to  use 
the  sutures  as  shown  in  the  accompanying  figures,  most  surgeons 
today  employ  rubber  covered  clamps,  as  in  other  operations  upon 
the  stomach  and  intestines.  The  main  points  on  which  stress  is  laid 
by  Finney,  are  the  very  thorough  separation  of  the  peri-pyloric  ad- 
hesions, and  the  large  size  of  the  gastro-duodenal  incision,  which 
should  be  not  less  than  12  cm.  (over  four  inches  and  a  half). 

The  operation  is  described  by  Finney  as  follows  (Trans.  Amer. 
Surg.  Assoc,  1902;  XX,  165):  "Divide  the  adhesions  binding  the 
pylorus  to  the  neighboring  structures,  also  free  as  thoroughly  as 
possible  the  pyloric  end  of  the  stomach  and  first  portion  of  the  duo- 
denum. Upon  the  thoroughness  with  which  the  pylorus,  lower  end  of 
the  stomach  and  upper  end  of  the  duodenum  are  freed,  depends  in 

•  According  to  a  recent  note  in  tlie  Centr.  f.  Chir.  (1920,  .xlviii,  509;  a  number  of  similar 
operations  have  been  done  within  recent  years  in  Germany:  .'Vxhausen,  5  cases,  i  death; 
Hinz,  2  cases,  i  death;  Hirschmann,  2  cases,  results  not  given.  Kirschner  is  quoted  as 
liaving  freed  the  stomach  from  all  its  connections  except  with  the  duodenum,  preserving 
only  the  latter,  and  the  gastric  and  the  right  epiploic  arteries;  the  stomach  is  then  drawn  up 
extra-thoracically  to  the  cervical  esophagus,  with  which  the  fundus  of  the  stomach_(,not 
the  cardia)  is  directly  united.     His  patient  recovered. 


FINNEY  S    PYLOROPLASTY  327 

large  measure  the  success  of  the  operation  and  the  ease  and  rapidity 


Fig,  91. — Finney's   Method  of  Pyloroplasty.     The   Traction   Sutures   Inserted. 

of  its  performance.     I  wish  to  emphasize  this  as  one  of  the  most  im- 
portant points  in  the  operation.     Frequently  at  first  sight  the  pylorus 


Fig.  92. — Finney's     Pyloroplasty.      The     Posterior     Continuous    Sero-serous     Suture    is 

Applied. 

may  seem  hopelessly  bound  down,  when,  after  a  little  patient  toil  and 


328    TECHNIQUE   OF  OPERATIONS   ON  THE   STOMACH  AND  DUODENUM 

the  judicious  use  of  the  scalpel  and  blunt  dissector,  it  is  found  that  it 
can  be  freed  with  comparative  ease.  A  suture,  to  be  used  as  a  retrac- 
tor, is  taken  in  the  upper  wall  of  the  pylorus,  which  is  then  retracted 
upward.  A  second  suture  is  then  inserted  into  the  anterior  wall  of 
the  stomach,  and  a  third  into  the  anterior  wall  of  the  duodenum  at 
equidistant  points,  say  about  12  cm.  from  the  suture  just  described 
in  the  pylorus.  These  second  sutures  mark  the  lower  end  of  the 
gastric  and  duodenal  incisions,  respectively.  They  should  be  placed 
as  low  as  possible  in  order  that  the  new  pylorus  may  be  amply  large. 
Traction  is  then  made  upward  on  the  pyloric  suture,  and  downward 


Fig.  93. — Finney's  Pyloroplasty.     The  Mattress  Sutures  Inserted. 

in  the  same  plane,  on  the  gastric  and  duodenal  sutures.  This  keeps 
the  stomach  and  the  duodenal  wall  taut,  and  allows  the  placing  of  the 
sutures  with  greater  facility  than  if  the  walls  remained  lax  (Fig.  91). 
The  peritoneal  surfaces  of  the  duodenum  and  stomach  along  its 
greater  curvature  are  then  sutured  together  as  far  posteriorly  as 
possible  (Fig.  92).  For  this  row  I  would  recommend  the  use  of  the 
continuous  suture,  as  it  is  more  easily  and  quickly  applied,  and  it  can 
be  reinforced  after  the  stomach  and  duodenum  have  been  incised. 
After  the  posterior  line  of  sutures  has  been  placed,  an  anterior  row  of 
mattress  sutures  is  taken,  which  are  not  tied,  but  left  long,  in  the 
manner  indicated  in  Fig.  93.  These  sutures,  after  they  have  been 
placed,  are  retracted  vertically  in  either  direction  from  the  middle  of 
the  portion  included  in  the  row  of  sutures  (Fig.  94).  Then,  after  all 
the  stitches  have  been  placed  and  retracted,  the  incision  is  made  in 


Finney's  pyloroplasty 


329 


the  shape  of  a  horseshoe.  The  sutures  should  be  placed  far  enough 
apart  to  give  ample  room  for  the  incision.  The  gastric  arm  of  the 
incision  is  made  through  the  stomach  wall  just  inside  the  lowest  point 
of  the  line  of  sutures,  and  is  carried  up  to  and  through  the  pylorus  and 
around  into  the  duodenum,  down  to  the  corresponding  point  on  the 
duodenal  side.  Hemorrhage  is  then  stopped.  It  is  well  to  excise  as 
much  as  possible  of  the  scar  tissue  upon  either  side  of  the  incision  in 
order  to  limit  as  far  as  possible  the  subsequent  contraction  of  the 
cicatrix.     It  is  well,  too,  to  trim  off  with  scissors  redundant  edges  of 


Fig.  94. — Finney's  Pyloroplasty.  The  Mattress  Sutures  Having  Been  Drawn  Upward 
and  Downward,  the  Stomach  and  Duodenum  are  Opened  by  a  Long  Hair  Pin  Shaped 
Incision. 


mucous  membrane  at  the  new  pylorus.  A  continuous  catgut  suture 
is  now  taken  through- and- through  all  the  coats  of  the  intestine  on  the 
posterior  side  of  the  incision  (Fig.  95).  This  reinforces  the  posterior 
line  of  sutures,  secures  better  approximation  of  the  cut  edges  of  the 
mucous  membrane,  and  prevents  the  reunion  of  the  divided  intestinal 
walls.  The  anterior  sutures  are  then  straightened  and  tied,  and  the 
operation  is  complete,  unless  one  wishes  to  reinforce  the  mattress 
sutures  with  a  few  Lembert  stitches"  (Fig.  96). 

The  only  modifications  which  we  have  adopted  in   the  limited 


SSO   TECHNIQUE   OF  OPERATIONS   ON   THE   STOMACH   AND   DUODENUM 

number  of  cases  in  which  this  operation  has  been  done,  consist  in 
(i)  the  use  of  clamps;  (2)  continuing  the  through-and-through  cat- 
gut sutures  all  around  the  gastro-intestinal  anastomosis,  as  in  other 
forms  of  lateral  anastomosis,  instead  of  only  on  the  posterior  surfaces 
of  the  incision,  as  recommended  by  Finney;  and  (3)  in  omitting  the 
anterior  row  of  mattress  sutures,  their  place  being  taken  by  a  con- 
tinuation of  the  posterior  row  of  Lembert  sutures  first  applied.  In 
other  words,  we  do  the  ordinary  operation  of  lateral  anastomosis,  as  in 
gastro-enterostomy  or  entero-enterostomy. 


Fig.  95. — Finney's  Pyloroplasty.     The  Adjacent  Margins  of  the  Gastric  and  Duodenal 
Incisions  Have  Been  United  by  a  Continuous  Through-and-through  Suture. 

Durante's  Pyloroplasty. — According  to  Ricard  and  Chevrier  (1905) 
Durante  adopted  a  form  of  pyloroplasty  in  which  a  Y-shaped 
incision  is  made  through  the  pyloric  vah'c  and  the  pyloric  portion  of 
the  stomach.  The  stem  of  the  Y  divides  the  pylorus,  and  into  the 
incision  thus  made,  the  triangular  flap  included  between  the  branches 
of  the  Y  is  drawn  and  sutured,  thus  increasing  the  diameter  of  the 
pylorus  at  the  expense  of  the  anterior  gastric  wall.  The  principle 
is  the  same  as  in  NicoH's  operation  for  infantile  stenosis  of  the  pylorus 

(P-  137)- 

Kocher's  Method  of  Lateral  Gastro-duodenostomy  is  rendered 
possible    by   mobilization    of    the   duodenum,  adopted  years  ago  by 


GASTRO-JEJUNOSTOMY  331 

Finney,  and  subsequently  popularized  by  Kocher.  Leriche  (1906) 
gives  the  history  of  this  preliminary  step,  the  idea  of  mobilizing  the 
duodenum  apparently  having  originated  with  Terrier.  The  operation 
resembles  that'of  Finney,  except  that  the  pylorus  itself  is  not  divided. 


Fig.  96. — Finney's  Pyloroplasty:  the  Operation  is  Completed  by  Straightening  Out  and 

Tying  the  Mattress  Sutures. 

Gastro-jejunostomy 

Historical. — The  operation  was  first  performed  in  1881  (at  the 
suggestion  of  his  assistant  Nicoladoni),  by  Wolfler.  The  case  was 
one  of  pyloric  carcinoma,  and  when  this  was  found  to  be  inoperable, 
Wolfler  was  about  to  close  the  abdomen,  when  Nicoladoni  suggested 
that  by  anastomosing  the  small  bowel  with  the  anterior  wall  of  the 
stomach  a  new  exit  for  the  food  would  be  provided.  Although  in 
this  original  operation  the  jejunum  was  attached  to  the  stomach  in  an 
anti-peristaltic  direction  (that  is,  with  its  anal  end  toward  the  cardiac 
end  of  the  stomach),  yet  it  is  customary  to  speak  in  general  of  all 
anterior  gastro-jejunostomies  as  "Wolfier's  method."  In  1887  Rock- 
witz  introduced  an  operation  in  which,  by  attaching  the  jejunum  to 
the  stomach  in  tlie  other  direction,  "iso-peristaltic"  action  was  ob- 
tained. In  1885  V.  Hacker  published  a  method  of  gastro-jejunostomy 
by  which  the  anastomosis  was  made  in  the  posterior  wall  of  the  stomach, 
through  an  opening  in  the  transverse  mesocolon.  He  used  an  afferent 
loop  of  jejunum  about  35  cm.  in  length.     Since  that  time  all  posterior 


332  TECHNIQUE  OF  OPERATIONS  ON  THE  STOMACH  AND  DUODENUM 


trans-mesocolic  gastro-jejunostomies  by  lateral  anastomosis  have  been 
described  in  general  as  by  v.  Hacker's  method. 

The  idea  of  a  gastro-jejunostomy  in-Y  is  attributed  by  Roux  (1897) 
to  Socin;  but  the  latter  credits  its  origin  to  Wolfler,  who  in  his  "  second  " 
method  adopted  this  technique  in  connection  with  anterior  gastro- 
jejunostomy. Roux  (1897)  calls  his 
own  method  "posterior  retro-colic 
gastro-enterostomyin-Y."  (Fig.  105.) 
The  idea  of  doing  an  entero- 
anastomosis  between  the  afferent  and 
efferent  loops  of  the  jejunum,  sup- 
posed to  prevent  the  discharge  of 
the  duodenal  secretions  into  the 
stomach,  is  due  to  Lauenstein,  who 
suggested  in  1891  the  anastomosis  of 
the  afferent  loop  with  a  neighbor- 
ing coil  of  intestine.  Braun  in  1892 
adopted  as  his  method  an  anas- 
tomosis between  the  afferent  and 
efferent  loops;  while  Jaboulay,  in  the 
same  year,  anastomosed  the  jeju- 
num below  the  gastro-jejunal  anas- 
tomosis with  the  third  portion  of  the 
duodenum.  To  make  certain  that 
the  contents  of  the  afferent  loop 
would  pass  directly  into  the  efferent, 
through  the  entero-anastomosis,  and 
not  continue  past  it  into  the  stom- 
ach, the  afferent  loop  (between  the 
stomach  and  the  entero-anastomosis) 
was  divided  and  both  ends  closed 
by  Doyen  in  1898;  while  Fowler, 
in  1902,  was  content  to  ligate  the 
afferent  loop  with  silver  wire.  Liicke 
in  1899  advocated  as  an  improve- 
ment on  Doyen's  method  an  oper- 
ation (Liicke's  second  method)  which  combined  the  merits  of  the 
Y-operation  with  the  advantages  of  the  enteroanastomosis  introduced 
by  Braun.  To  accomplish  this,  Lucke  divided  the  jejunum  completely 
25  to  40  cm.  (10  to  15  inches)  from  its  origin,  closed  both  ends,  and  then 
made  two  lateral  anastomoses — one  between  the  posterior  gastric  wall 


Pig.  97.- 


-Posterior  "No-loop"   Gastro- 
jejunostomy. 


GASTRO-JEJUNOSTOMY  T,^^ 

and  the  distal  segment  of  jejunum,  and  the  other  between  the  two 
segments  of  the  jejunum,  a  convenient  distance  below  the  stomach. 
By  this  means  he  avoided  the  end  to  side  implantations  of  Roux's 
method,  which  he  regarded  as  dangerous,  while  at  the  same  time  he 
retained  the  advantage  of  the  principle  of  the  Y-anastomosis,  which 
rendered  a  simultaneous  entero-anastomosis  unnecessary. 

The  most  valuable  modification  of  all  was  that  introduced  in  1901 
by  Petersen,  of  Czerny's  clinic:  in  this  operation,  a  posterior  trans- 
mesocolic  gastro-jejunostomy,  the  afferent  loop  was  abolished,  the 
anastomosis  in  the  jejunum  being  made  as  close  as  possible  to  the  duod- 
eno-jejunal  juncture  and  the  bowel  was  affixed  to  the  stomach  in  the 
long  axis  of  the  patient's  body,  that  is,  nearly  at  right  angles  to  the 
greater  curvature  (Figs.  97,  98).  This  remains  the  standard  oper- 
ation, and  has  superseded  the  "short  loop  method"'  formerly  taught 
by  Robson,  Moynihan,  Scudder,  and  Mayo. 

It  is  our  purpose  to  describe  only  the  following  methods  of  perform- 
ing gastro-jejunostomy.  i.  Posterior  trans-mesocolic  gastro-jejunos- 
tomy without  a  loop.  2.  Anterior  ante-colic  gastro-jejunostomy 
with  clamps  or  the  Murphy  button.  3.  Roux's  gastro-jejunostomy 
in-Y. 

The  indications  for  the  employment  of  gastro-jejunostomy  have 
been  discussed  in  connection  with  the  various  afi'ections  for  which  it 
may  be  adopted. 

General  Considerations. — The  same  incision  will  suffice  no  matter 
what  method  be  adopted.  That  most  frequently  employed  is  a 
longitudinal  incision  through  the  right  rectus  muscle,  close  to  the  me- 
dian line.  It  should  be  about  four  inches  (10  cm.)  in  length,  extending 
from  below  the  ensiform  process  nearly  to  the  umbilicus.  A  very  care- 
ful examination  should  be  made  of  the  whole  operative  field  before  com- 
mencing the  gastro-intestinal  anastomosis,  since  it  occasionally  happens 
that  some  other  method  than  that  originally  designed  will  be  required 
to  meet  the  condition  found.  Especially  important  is  it  to  determine 
the  extent  of  the  whole  stomach,  for,  as  Moynihan  has  pointed  out, 
neglect  of  this  precaution  may  result  in  the  surgeon  overlooking  the 
existence  of  an  hour-glass  stomach  with  small  cardiac  pouch.  We 
think  the  preference  of  the  operator  should  always  be  for  a  posterior 
gastro-jejunostomy;  hence  his  next  step  should  be  to  determine  whether 
the  posterior  wall  of  the  stomach  is  accessible  through  the  transverse 
mesocolon.     Before  proceeding  with  this  search,  the  entire  skin  sur- 

'  "Short-loop  method"  to  distinguish  it  from  the  original   "long-loop  method"  of 
V.  Hacker. 


334    TECHNIQUE   OF  OPERATIONS  ON   THE   STOMACH  AND  DUODENUM 

face  surrounding  the  abdominal  incision  should  be  covered  with  hot 
moist  gauze  pads,  in  order  to  protect  any  viscera  which  may  have  to  be 
drawn  out  of  the  abdomen.  By  now  drawing  the  great  omentum 
with  its  attached  transverse  colon  into  the  wound,  and  turning  them 
upward  on  to  the  hot  gauze  pads  already  placed  over  the  epigastrium 
and  lower  thorax,  the  transverse  mesocolon  is  readily  brought  to  view. 
If  the  stomach  is  densely  adherent  to  the  mesocolon  and  the  pancreas 
it  will  be  impossible  to  withdraw  the  transverse  colon  in  this  way;  but 
even  after  this  manoeuvre  has  been  easily  accomplished  and  the  poste- 
rior gastric  wall  exposed  by  division  of  the  mesocolon,  it  may  be  found 
that  there  is  not  a  sufiicient  area  of  healthy  gastric  wall  to  permit  of 
an  anastomosis  being  made  in  its  posterior  surface.  Under  these  cir- 
cumstances the  upper  coil  of  jejunum  should  be  identified  before  re- 
placing the  transverse  colon;  neglect  of  this  precaution  may  result  in 
the  surgeon  subsequently  selecting  the  wrong  coil  of  small  intestine  for 
his  anastomosis.  We  know  of  several  instances  in  which  accomplished 
operators  have  by  mistake  anastomosed  the  lower  ileum  to  the  stomach. 
By  pulling  the  transverse  colon  and  the  attached  great  omentum,  as 
already  described,  out  of  the  abdominal  wound,  the  primary  coil  of 
the  jejunum  is  readily  brought  into  view  (Fig.  98). 

It  is  important,  whenever  possible,  to  make  the  anastomosis  near  the 
pyloric  portion  of  the  stomach,  so  that  the  new  opening  shall  resemble 
the  pylorus  as  nearly  as  possible  in  its  physiological  action. 

Before  the  gastro-intestinal  anastomosis  is  commenced,  the  surgeon 
should  isolate  by  the  use  of  gauze  packs  the  immediate  structures  in- 
volved, and  all  viscera  outside  of  the  abdomen  must  be  carefully  cov- 
ered with  hot  moist  gauze.  One  piece  of  gauze  should  always  be 
passed  just  beneath  the  site  of  the  proposed  anastomosis,  to  be  with- 
drawn on  its  completion.  Usually,  after  the  posterior  wall  of  the 
stomach  has  been  exposed  through  the  transverse  mesocolon,  it  will 
be  found  possible  to  replace  within  the  abdomen  both  the  transverse 
colon  and  the  stomach  itself,  before  proceeding  with  the  operation. 

Before  beginning  any  operation  in  which  it  is  proposed  to  use  the 
Murphy  button,  its  mechanism  should  be  scrupulously  and  repeatedly 
tested  by  the  surgeon  himself.  The  lumen  of  each  half  of  the  button 
should  be  tilled  with  cacao  butter;  this  prevents  escape  of  visceral 
contents,  but  will  be  melted  by  the  heat  of  the  body  a  few  moments 
after  the  anastomosis  has  been  completed  (Hartmann). 

Posterior  Gastro-jejimostomy.^The  transverse  colon  and  the 
attached  omentum  are  drawn  out  of  the  wound,  and  by  pulling  tliese 
structures  upward  and  to  the  patient's  right  the  transverse  mesocolon 


POSTERIOR   TRANSMESOCOLIC    GASTRO-JEJUNOSTOMY 


335 


is  put  upon  the  stretch  and  the  origin  ot  the  jejunum  brought  into 
sight.  This  is  then  caught  hghtly  in  toothed  forceps,  placed  on  its 
antimesenteric  border,  about  5  cm.  apart,  and  the  right  portion  of  the 
three-bladed  intestinal  anastomosis  forceps  is  adjusted  so  as  to  include 
at  least  10  cm.  of  the  jejunum  in  its  grasp  (Fig.  98). 


Fig.  98. — Posterior  Transmesocolic  Gastro-jejunostomy.  The  Transverse  Colon  has 
been  Drawn  from  the  Wound.  Making  Taut  the  Transverse  Mesocolon,  which  has  Been 
Opened,  Exposing  the  Posterior  Wall  of  the  Stomach;  the  Jejunum  is  to  be  Anastomosed 
to  the  Stomach  (a  to  a'  and  b  to  b')- 

The  point  of  emergence  of  the  jejunum  from  the  transverse  mesocolon 
corresponds  in  most  instances  very  closely  to  the  duodeno-jejunal 
juncture;  but  in  a  small  proportion  of  cases  the  jejunum  is  retro- 
peritoneal for  a  variable  distance  from  its  origin  before  leaving 
the  posterior  parietal  peritoneum  and  becoming  invested  by  the 
mesentery.     It  is  important  for  the  surgeon,   therefore,  critically  to 


336    TECHNIQUE  OF  OPERATIONS   ON  THE   STOMACH  AND  DUODENUM 

examine  the  supposed  primary  coil  of  jejunum,  and  to  make  sure  that 
no  abnormahty  will  cause  him  to  perform  a  long  loop  operation  when 
he  aims  to  leave  no  loop  at  all.  If  a  peritoneal  fold  binding  the  jejunum 
to  the  mesocolon  is  recognized,  it  should  be  divided  up  to  its  origin 
and  the  anastomosis  may  be  made  in  the  raw  area  left  on  the  jejunum. 
Selecting  now  a  bloodless  area  to  the  left  of  the  main  trunk  of  the 
middle  colic  artery,  the  transverse  meso-colon  is  picked  up  with  dis- 
secting forceps  and  carefully  divided,  and  the  opening  enlarged  in 
the  sagittal  plane,  by  a  few  snips  with  scissors,  until  it  is  about  8  or 
10  cm.  in  length.  The  left  hand  of  the  operator,  which  holds  the 
transverse  colon  between  finger  and  thumb,  the  fingers  being  on  the 
upper  surface,  can  now  make  the  posterior  gastric  wall  protrude  into 
this  opening  in  the  transverse  mesocolon.  It  will  usually  be  found  that 
the  portion  of  the  gastric  wall  thus  brought  to  view  is  that  immediately 
beneath  the  lesser  curvature  and  that  it  is  quite  close  to  the  greater 
curvature  of  the  stomach.  The  stomach  wall  is  caught  by  toothed 
forceps,  or  by  light  ring-bladed  rubber  covered  forceps,  in  two  places, 
about  5  cm.  apart,  picking  up  a  fold  of  the  stomach  which  runs  in  the 
long  axis  of  the  patient's  body  (Fig.  98).  The  base  of  the  fold  of 
gastric  wall  thus  grasped  should  be  from  8  to  10  cm.  in  length  and 
the  portion  grasped  should  be  in  the  pyloric  portion  of  the  stomach. 
The  clamp  should  not  be  applied  parallel  to  the  greater  curvature  of  the 
stomach,  since  to  do  so  would  markedly  distort  the  jejunum,  which  at 
its  origin  runs  more  or  less  perpendicularly  to  the  greater  curvature  of  the 
stomach  (Fig.  103).  Mayo  urged  (1906)  that  the  incision  be  made  ob- 
liquely downward  and  to  the  left,  claiming  that  this  preserves  the  normal 
anatomical  relations  better,  and  that  the  fact  of  the  anti-peristaltic 
direction  of  the  anastomosis  thus  effected  is  of  no  consequence.  But  as 
Moynihan  (1908)  pointed  out,  the  jejunum  is  quite  freely  movable  below 
the  ligament  of  Treitz,  and  if  found  running  downward  and  to  the  left 
while  patients  are  on  their  backs,  may  also  be  found  running  down- 
ward and  to  the  right  if  they  are  made  to  lie  on  their  right  side.  There- 
fore it  seems  best  to  adhere  to  the  method  of  Petersen,  who  made  the 
opening  in  the  stomach  practically  at  right  angles  to  its  greater  curva- 
ture, or  perhaps  inclined  a  httle  to  the  right  Moynihan  laid  stress 
on  the  importance  of  not  rotating  the  jejunum  on  its  long  axis,  as  this 
may  cause  obstruction  at  the  duodeno-jejunal  flexure.  A  small  piece 
of  gauze  is  then  laid  beneath  the  parts  to  be  approximated,  and  the  left 
blades  of  the  threc-bladed  clamps  are  adjusted  to  the  stomach  in  such  a 
manner  that  the  aboral  end  of  jejunum  corresponds  with  the  greater  curva- 
ture of  the  stomach,  and  its  duodenal  end  with  the  lesser  curvature  of 


POSTERIOR   TRANSMESOCOLIC   GASTRO-JEJUNOSTOlWy 


337 


the  stomach  (Fig.  98,  a  with  a',  b  with  b').  The  transverse  colon  and 
all  the  viscera  not  immediately  concerned  in  the  anastomosis  are  then 
replaced  inside  the  abdomen,  and  the  entire  operative  field  is  isolated 
by  sterile  gauze.  The  stomach  and  the  jejunum,  which  are  maintained 
in  apposition  by  the  clamps,  are  now  to  be  united  by  a  posterior  sero- 
serous  continuous  suture  of  linen  thread.  This  suture  should  be  applied 
as  close  as  possible  to  the  blades  of  the  clamp,  so  as  to  leave  plenty  of 
room  for  the  through-and  through  sutures.  The  posterior  row  of 
sutures  should  commence  a  little  beyond  one  extremity  of  the  proposed 
anastomosis,  and  is  to  be  continued  a  little  past  the  other  end,  where  it 
may  be  knotted  to  prevent  puckering  of  the  anastomosis  (as  advised 


., 

ttsit!'^/";  >^^ 

d 

pt^      — j; 

^, 

]M 

^  ■♦i^^^. 

■'■■^ Jg 

/ 

^^0^'^^- 

_ 

/ 

Fig.  99. 


by  Hartmann).  The  ends  of  this  suture  should  be  left  long,  and,  with 
the  needle  still  threaded,  it  should  be  laid  aside  and  covered  with 
sterile  gauze  until  again  needed  (Fig.  99). 

An  incision  about  6  cm.  long  is  now  made  with  a  scalpel  through 
the  serous  and  muscular  coats  of  the  stomach,  about  one  centimetre 
distant  from  the  continuous  suture  just  inserted.  When  the  mucous 
layer  of  the  gastric  wall  is  thus  exposed,  it  will  pout  a  little  into  the 
incision;  the  jejunum  should  be  opened  in  a  similar  manner,  and  for  an 
equal  distance.  Before  either  stomach  or  jejunum  is  opened  it  is 
the  custom  of  the  senior  author  at  present  to  suture  together  the  adjoin- 
ing lips  of  the  incisions  in  the  stomach  and  jejunum,  with  a  continuous 
suture  of  chromic  gut.  In  this  he  follows  the  teaching  of  Mayo,  be- 
lieving that  better  hemostasis  is  thus  secured.     It  may  be  that  this 


338    TECHNIQUE   OF  OPERATIONS   ON   THE   STOMACH  AND  DUODENUM 

Step  will  be  abandoned  in  the  future  as  unnecessary.-'  Then  the  mucous 
coats  of  stomach  and  jejunum  are  opened,  by  picking  them  up  in  forceps 
and  cautiously  cutting  into  their  lumens  with  scalpel.  The  incisions  in 
the  mucosa  are  then  enlarged  with  scissors  the  full  length.  If  redun- 
dant some  of  the  pouting  mucous  membrane  may  be  excised.  It  is 
always  more  redundant  in  the  jejunum  than  in  the  stomach. 

The  surgeon  now  has  the  cavity  of  the  stomach  and  that  of  the 
jejunum  opened.  He  should  next  unite  the  adjacent  free  edges  of 
these  viscera  by  a  through-and-through  continuous  suture  of  chromi- 
cised  (or  iodized)  catgut.  Beginning  at  one  extremity  of  the  incisions 
into  stomach  and  jejunum,   the  needle  is  passed   from   the  mucous 


Fig.  100. 


surface  of  the  jejunum  through  its  wall  to  its  serous  surface,  and  from 
the  serous  surface  of  the  stomach  into  the  cavity  of  the  latter.  The 
suture  is  then  fixed  by  knotting  it;  and  by  continuing  to  suture  in  a 
precisely  similar  manner  the  posterior  margins  of  the  incisions  are  united 
from  one  extremity  to  the  other  (Figs.  loo,  loi).  The  suture  may 
be  knotted  from  time  to  time  if  desired,  to  prevent  puckering,  as  taught 
by  Hartmann ;  usually  this  is  unnecessary.  When  the  surgeon  reaches  the 
end  of  the  posterior  margins  of  the  gastric  and  jejunal  incisions,  he  should 
continue  his  suture  carefully  around  the  end  (Fig.  102,  .4),  and  begin  the 
approximation  of  their  anterior  margins.     As  these  are  not  held  in  close 

'  Certainly  it  should  be  unnecessary,  theoretically,  as  a  continuous  overhand  through- 
and-through  suture  such  as  is  currently  employed  here  by  most  operators  is  more  of  a 
safeguard  against  bleeding  from  the  cut  edges  of  stomach  and  bowel,  than  is  the  right- 
angled  through-and-through  suture  which  is  employed  to  unite  the  anterior  lips  of  the 
anastomosis  where  the  danger  from  bleeding  is  equal,  and  yet  where  Mayo  considers  no 
e.xtra  hemostatic  suture  is  necessary. 


POSTERIOR    TRANSMESOCOLIC   GASTRO-JEJUNOSTOMY 


339 


apposition  by  the  clamps,  as  were  the  posterior  margins,  it  is  a  little 
difficult  at  first  to  understand  how  to  continue  the  suture  so  as  to 
secure  the  approximation  of  serosa  to  serosa.  If  the  surgeon,  however, 
pursues  precisely  the  same  method  already  adopted,  he  will  have  no 
trouble  with  this  part  of  the  operation;  he  should  pass  his  needle  from 
the  mucous  surface  of  the  jejunum  to  its  serous  surface,  then  from  the 
serous  surface  of  the  stomach  to  its  mucous  surface,  draw  the  stitch 
tight,  and  repeat  the  process.  To  put  it  briefly,  the  needle  is  passed 
out,  in,  and  over;  out,  in  and  over;  etc. — that  is  to  say,  out  of  one 
organ,  into  the  other,  and  over  the  fine  of  sutures,  again  to  pass  out  of 
the  jejunum,  into  the  stomach,  and  across  the  suture  line  back  to  the 


Fig.   ioi. 

starting  point.  By  drawing  each  stitch  fairly  tight,  it  is  easy  to  deter- 
mine the  point  where  the  needle  should  next  be  inserted.  About  four 
or  five  stitches  should  be  made  to  every  inch  (or  one  to  every  0.5  cm.) 
When  the  angle  of  the  incision  has  been  successfully  turned  in  this 
manner,  it  is  easier  to  secure  inversion  of  the  anterior  lips  of  the 
anastomosis  by  employing  a  continuous  right-angle  suture  of  the  ty^c 
represented  in  Fig.  102,  B:  in  this  the  needle  after  entering  one  organ 
from  its  serous  to  its  mucous  surface  at  once  retraces  its  step,  leaving 
the  loop  of  the  suture  on  the  mucous  surface;  the  needle  is  then  carried 
across  to  the  opposite  lip  of  the  anastomosis,  entering.it  from  its  serous 
surface,  at  once  retracing  its  course  from  mucous  to  serous  surface, 
again  leaving  the  loop  of  the  suture  on  the  mucous  surface.  This  brings 
broad  areas  of  serous  surface  into  contact  and  prevents  prolapse  of  the 
mucous  membrane  between  the  stitches.  When  the  entire  circumference 
of  the  anastomosis  has  been  united  by  this  through-and-through  suture, 


34°   TECHNIQUE   OF   OPERATIONS  ON  THE   STOMACH  AND  DUODENUM 

the  catgut  thread  is  tied  to  its  own  original  end,  at  the  starting  point, 
and  cut  short.  The  sero-serous  suture,  previously  laid  aside,  is  now  to 
be  resumed,  reinforcing  the  anastomosis  on  its  anterior  aspect,  and 


Pig.  102. — Posterior  Gastro-jejunostomy.  At  A:  the  Through-and-through  Suture  is 
Shown  Turning  the  Angle  of  the  Incisions  in  Stomach  and  Jejunum;  at  B,  It  is  Inverting 
the  Anterior  ^.ips,  as  a  Through-and-through  Right-angled  Suture.  The  Central  Drawing 
Shows  the  Anastomosis  Completed  by  Continuing  the  Original  Sero-serous  Suture  Back 
again  to  Its  Starting  Point.  It  also  Indicates  how  the  Cut  Edges  of  the  Mesocolon  are 
Sutured  to  the  Stomach. 

completing  the  circumference  of  the  wound  to  its  starting  point,  where 
it  is  to  be  tied  to  its  own  initial  extremity  and  cut  short. 

It  is  advisable,  as  soon  as  the  through-and-through  sutures  have  been 
completed,  and  all  danger  of  contamination  from  gastric  or  intestinal 


ANTERIOR    GASTRO-JEJUNOSTOMY  34I 

contents  has  been  thus  eliminated,  to  release  the  rubber  covered  clamps; 
for  it  is  not  desirable  to  keep  them  in  place  too  long,  as  there  is  always 
a  possibility  of  long  continued  pressure  injuring  the  gastric  or  intestinal 
walls.  It  is  convenient,  however,  to  lieep  one  blade  beneath  the 
anastomosis,  as  a  sort  of  bridge  to  hold  the  viscera  in  place,  until 
the  anterior  sero-serous  sutures  have  been  completed  (Fig.  102).  If 
any  bleeding  point  is  observed  when  the  clamps  are  removed,  it  should 
be  caught  up  in  a  special  suture. 

When  the  gastro-intestinal  anastomosis  has  been  finished  in  this 
manner,  the  surgeon  should  thoroughly  rinse  his  gloved  hands  in  cor- 
rosive sublimate  and  then  in  sterile  water.  It  is  often  befter  to  put 
on  another  pair  of  sterile  gloves. 

The  edges  of  the  opening  in  the  mesocolon  are  next  to  be  sutured  to 
the  gastric  wall  a  short  distance  away  from  the  anastomosis  (Fig.  102). 
This  is  a  very  important  step  in  the  operation,  and  should  never  be  for- 
gotten. It  prevents  prolapse  of  coils  of  small  bowel  into  the  lesser 
peritoneal  cavity,  and  also  keeps  the  mesocolon  from  constricting  the 
anastomosis  itself  or  from  slipping  down  over  the  afferent  and  efferent 
loops  of  jejunum  and  thus  causing  obstruction.  It  is  well  to  place  a 
stitch  at  each  extremity  of  the  opening  in  the  mesocolon  to  keep  the 
incision  from  tearing  larger. 

The  gauze  surrounding  the  field  of  operation  is  now  to  be  removed ; 
as  that  piece  of  gauze  immediately  underlying  the  anastomosis  is  drawn 
out  it  will  rotate  the  anastomosed  struc- 
tures far  enough  to  enable  the  surgeon  to 
inspect  the  posterior  line  of  sutures,  and 
thus  to  assure  himself  that  all  is  in  good 
condition  on  that  surface  of  the  anas- 
tomosis. 

The  viscera  are  then  carefully  replaced 
in  the  abdomen,  the  great  omentum  is 
drawn  down  over  the  small  intestines,  and   pig.  103!— Diagram  of  Posterior 

the  abdominal  wound  is  closed.  No-loop  Gastro-jejunostomy. 

Anterior  Gastro-jejunostomy, —  The  primary  loop  of  the  jeju- 
num is  identified  by  withdrawing  the  transverse  colon  from  the  wound, 
and  seeking  the  duodeno-jejunal  juncture  in  the  transverse  mesocolon 
just  to  the  left  of  the  spinal  column.  The  transverse  colon  is  then 
replaced  in  the  abdomen,  and  a  point  on  the  jejunum  is  selected  which 
will  reach  the  anterior  wall  of  the  stomach  without  constricting  the 
transverse  colon.  This  is  usually  40  to  60  cm.  (16  to  24  inches)  below 
the  origin  of  the  jejunum.     It  is  not  necessary,  nor  is  it  desirable,  to 


342    TECHNIQUE   OF   OPERATIONS   ON   THE   STOMACH  ANT3   DUODENUM 

split  the  great  omentum  up  to  the  transverse  colon  so  as  to  render  the 
use  of  a  shorter  loop  possible  but  the  jejunum  should  be  brought  up 
to  the  left  of  the  omentum,  which  is  displaced  toward  the  patient's 
right  (not  as  shown  in  Fig.  104  toward  the  patient's  left).  We  prefer 
to  make  the  anastomosis  with  the  clamps,  the  technique  employed  being 
the  same  as  that  described  under  the  heading  of  posterior  gastro-jeju- 
nostomy  (p.  338).     If  the  Murphy  button  is  to  be  used,  a  purse-string 


bfas'/TWi-. 


-"^■^^ 


Pig.  104. — Anterior  Gastro-jejunostomy  with  the  Murphy  Button. 


suture  of  linen  is  inserted  in  a  healthy  portion  of  the  anterior  gastric  wall, 
near  the  greater  curvature,  and  if  possible  in  the  pyloric  portion  of  the 
stomach.  A  similar  purse-string  suture  is  also  applied  to  the  jejunum, 
at  the  point  selected,  opposite  the  mesenteric  attachment.  Each  of 
these  sutures  should  encircle  a  space  just  large  enough  to  permit  of 
the  introduction  of  a  Murphy  button;  the  sutures  should  not  be  tied. 


GASTRO-JEJUNOSTOMY    IN-Y  343 

and  the  ends  should  be  left  long,  to  permit  of  pulling  the  suture  tight 
after  each  half  of  the  button  has  been  introduced. 

After  these  sutures  have  both  been  placed,  an  incision  should  be 
made  in  the  gastric  wall  within  the  circle  formed  by  the  purse-string 
suture,  and  the  male  half  of  the  button,  held  in  the  bite  of  a  hemo- 
stat,  should  be  quickly  passed  into  the  incision.  The  gastric  suture 
is  then  drawn  tight,  tied,  and  cut  close.  The  jejunum  is  opened 
in  a  similar  manner,  the  female  half  of  the  button  is  passed  into  the 
incision,  is  fixed  by  tying  the  pursestring  suture;  and  then  the  two 
halves  are  approximated  and  pushed  home.  A  few  interrupted  Lem- 
bert  sutures,  or  a  continuous  suture,  may  then  be  introduced  around 
the  margins  of  the  button.  The  packs  are  then  withdrawn,  the 
viscera  suitably  replaced  in  the  abdomen,  and  the  abdominal  wound 
closed. 

It  is  proper  to  note  in  this  place  that  the  Murphy  button  was  not 
approved  in  recent  years  by  its  inventor  for  use  in  anterior  gastro- 
jejunostomy. While  it  is  true  that  the  operation  may  be  done  equally 
well  by  the  use  of  clamps  and  suture,  without  a  button,  yet  when  it 
is  desired  to  complete  the  operation  rapidly,'  we  believe  no  method 
is  so  satisfactory  as  the  use  of  the  Murphy  button.  And  although  we 
employ  the  clamps  whenever  possible,  we  have  elected  to  describe  the 
use  of  the  Murphy  button  in  connection  with  anterior  gastro-jejunos- 
tomy,  because  that  is  about  the  only  form  of  gastro-intestinal  anastomo- 
sis in  which  the  surgeon  cannot  invariably  dispense  with  such  an  aid. 
Murphy  modified  the  button  so  that  an  oval  instead  of  a  circular  open- 
ing may  be  made;  but  we  have  had  no  personal  experience  with  this 
newer  form. 

Posterior  Gastro-jejunostomy  in-Y  (Roux)  (Fig.  105). — Deliver  the 
transverse  colon,  and  draw  out  of  the  abdomen  the  first  coil  of  the  jeju- 
num, and  empty  it  of  its  contents  by  manipulation  with  the  fingers  for  a 
distance  of  about  30  cm.  Apply  a  long  rubber  covered  clamp  across 
its  lumen  in  two  places,  leaving  an  omega  loop  of  at  least  25  cm.,  with 
its  mesentery,  hanging  free  beyond  the  clamp.  Or  if  it  seems  undesirable 
to  clamp  the  entire  blood  supply  for  so  long  a  time,  the  surgeon  may 
employ  two  smaller  clamps,  each  constricting  the  entire  lumen  of  the 
jejunum,  about  25  cm.  distant  one  from  the  other.  The  proximal 
point  of  the  jejunum  clamped  should  be  about  25  cm.  below  the 
duodeno-jejunal  juncture.  Next  divide  the  jejunum  completely  across 
about  10  cm.  below  where  the  clamp  compresses  its  proximal  end. 
This  will  leave  two  segments  of  jejunum  within  the  grasp  of  the  clamp : 
the  proximal  segment  will  be  about  10  cm.  and  the  distal  about  15 


344    TECHNIQUE   OF   OPERATIONS   ON   THE   STOMACH  AND  DUODEXUil 


cm.  long.  The  posterior  wall  of  the  stomach  is  then  exposed  by  open- 
ing the  transverse  mesocolon,  is  caught  in  another  pair  of  rubber 
covered  anastomosis  clamps,  and  is  opened  for  a  distance  of  3  to  4  cm. 
Then  the  surgeon  unites  by  terminolateral  implantation  the  open 
circular  end  of  the  distal  jejunal  loop  with  the  stomach,  applying  first  a 
posterior  sero-serous  suture,  then  a  through-and-through  hemostatic 
suture,  which  passes  entirely  around  the  anastomosis;  and  finally  the 
posterior  sero-serous  suture  is  resumed,  re-inforcing  the  gastro-intestinal 

anastomosis  on  its  anterior  aspect.  Then 
an  incision  is  made  in  the  distal  segment  of 
jejunum  opposite  the  mesenteric  attachment, 
about  2.5  cm.  from  the  point  where  it  is 
clamped,  and  the  proximal  segment  is  im- 
planted into  this  incision,  in  precisely  the 
same  manner  (terminolateral  anastomosis)  as 
that  in  which  the  jejunum  has  just  been  united 
to  the  stomach.  The  clamps  may  now  be 
removed.  If  the  gastric  clamp  be  removed 
before  the  second  anastomosis  is  completed 
there  will  be  danger  of  leakage  of  gastric 
contents  through  the  lateral  incision  made  in 
the  jejunum  for  the  jejuno-jejunal  anas- 
tomosis. 

Before  closing  the  wound,  the  structures  should  be  carefully  ar- 
ranged in  the  abdomen;  and  the  surgeon  should  not  neglect  to  suture 
the  transverse  mesocolon  to  the  stomach  around  the  gastro-jejunal 
anastomosis,  nor  to  close  any  opening  in  the  mesentery  of  the  jejunum. 
Exclusion  of  the  pylorus  was  proposed  and  employed  in  1895  by 
V.  Eiselsberg.  The  operation  consists  in  dividing  the  stomach  com- 
pletely in  the  pre-pyloric  region,  closing  both  ends  by  suture,  and  then 
performing  posterior  gastro-jejunostomy.  Jonnesco  (1907)  preferred 
this  form  of  operation  to  a  simple  gastro-enterostomy,  and  always 
employed  it  when  excision  (pylorectomy;  partial  gastrectomy)  was 
impossible.     But  it  has  not  met  with  general  acceptance. 

We  have  already  expressed  our  preference  for  simple  gastro-jejun- 
ostomy and  we  cannot  see  that  this  operation  of  exclusion  .of  the 
pylorus  presents  any  particular  advantages  in  ordinary  cases.  When 
the  pylorus  is  freely  patulous,  there  will  be  a  tendency  for  the  gastric 
ulcers  to  heal  when  the  acidity  of  the  gastric  secretions  shall  have 
been  diminished  by  gastro-jejunostomy;  but  exclusion  of  the  ulcerated 
area  from  the  stomach  would  prevent  this  change  in  the  gastric  se- 


P I G.  105.  —  Diagram  of 
Roux's  Method  of  Posterior 
Gastro-jejunostomy  in-Y. 


GASTRO-GASTROSTOMY  345 

cretions  having  any  effect  on  the  ulcers,  while  at  the  same  time  it 
would  subject  the  patients  to  very  nearly  as  much  danger  as  would 
a  pylorectomy. 

.    Gastroplasty 

Gastroplasty,  an  operation  analogous  to  pyloroplasty,  is  adopted 
in  certain  cases  of  hourglass  constriction  of  the  stomach  (Fig.  io6). 
This  operation  is  said  to  have  been  employed  first  by  Bardeleben,  in 
1889.  The  first  patient  who  recovered  was  operated  upon  in  1892  by 
Krukenberg. 

A  rubber  covered  clamp  is  applied  to  the  stomach,  with  its  axis 
corresponding  to  the  long  axis  of  this  organ,  so  as  to  pick  up  in  its  grasp 
a  fold  of  gastric  wall  forming  the  channel  of  communication  between 
the  two  pouches  of  the  stomach.  This 
fold  of  gastric  wall  is  then  incised  down 
to  the  mucous  coat,  which  is  excised 
when  it  pouts  into  the  incision. 
Forceps  are  then  used  to  grasp  the 
margins  of  the  gastric  incision  at  its 
extremities  and  at  the  mid-point  of 
each  of  its  sides.  As  these  forceps  draw 
the  gastric  incision  well  upward,  the 
clamp  is  loosened,  removed,  and  reap- 
plied at  right  angles  to  its  former  p,^-  106.— Gastroplasty. 
position.     As  this  is  done  the  pairs  of 

forceps  formerly  at  the  mid-points  of  the  gastric  incision  are  separated 
so  as  to  change  the  formerly  longitudinal  incision  into  a  transverse 
wound,  while  the  forceps  formerly  at  the  ends  of  the  incision  will  now 
be  attached  to  its  sides.  The  rubber  covered  clamp  having  been 
reapplied,  the  gastric  incision  is  closed  by  a  through-and-through 
hemostatic  suture  of  iodized  catgut,  which  is  afterward  reinforced  by 
a  continuous  Lembert  suture  of  linen.  The  rubber  covered  clamps 
should  be  loosened  as  soon  as  the  through-and-through  suture  has  been 
completed,  to  test  its  hemostatic  effect;  and,  as  in  other  operations, 
any  bleeding  points  should  be  controlled  by  separate  sutures. 

Gastro-gastrostomy 

Gastro-gastrostomy,  an  operation  first  employed  in  cases  of  hour- 
glass stomach  by  Wolfler  in  1 894,  consists  in  making  a  lateral  anastomosis 
between  the  adjacent  parts  of  the  gastric  pouches  (Fig.  107) .  Two  rubber 
covered  clamps  are  applied  to  the  stomach,  one  in  the  cardiac,  the 


346    TECHNIQUE    OF   OPERATIONS   ON   THE   STOMACH   AND   DUODENUM 


Other  in  the  pyloric  pouch,  lying  parallel  to  each  other  and  transverse 
to  the  long  axis  of  the  stomach.  The  usual  technique  of  lateral  anasto- 
mosis by  suture  is  followed.     The  opening  should  be  at  least  8  cm. 


Fig.  107. — Gastro-gastrostomy. 


Fig.  ioS. — ^Gastro-auastomosis. 


long.     If  the  form  of  the  constriction  prevents  so  large  an  anasto- 
mosis, some  other  operation  should  be  employed. 

Gastro-anastomosis 

Gastro-anastomosis. —  This  term  ma}^  be  used  to  designate  an 
operation  for  hour-glass  stomach  analogous  to  Finney's  pyloroplasty, 
introduced  in  1903  by  Kammerer.     This  differs  from  gastro-gastros- 


r 


\ 


IS 


^^^t. 


\ 


T      >- 
V4      1 


^<^ 


Fig.  109. — Gastro-pUcation. 


Fig.  1 10. — Gastro-plication,  Seen  in  Sagittal 
Section. 


tomy  only  in  that  the  incisions  meet,  becoming  continuous  one  with 
the  other  through  the  anterior  wall  of  the  channel  connecting  the  two 
gastric  pouches  (Fig.  108). 


gastrectomy  347 

Gastro-plication 

Gastro-plication. — This  operation,  proposed  in  i8qi  by  Bircher, 
is  usually  done  by  Moynihan's  modification  of  Bennett's  method. 
Interrupted  Lembert  sutures  are  placed  in  the  anterior  gastric  wall, 
each  suture  picking  up  this  structure  in  four  or  five  places,  and  running 
from  the  greater  to  the  lesser  curvature,  transversely  to  the  long  axis 
of  the  stomach.  As  these  sutures  are  tightened,  the  anterior  wall 
of  the  stomach  is  puckered  up,  and  the  curvatures  approach  each  other, 
thus  diminishing  the  capacity  of  the  stomach  (Figs.  109  and  no). 

Gastropexy 

Gastropexy,  an  operation  designed  to  fix  a  proptosed  stomach, 
may  be  performed  by  either  Buret's  or  Beyea's  method. 

(i)  Buret's  Method  (1896).  The  abdomen  is  opened  through  the 
left  rectus  muscle,  but  the  parietal  peritoneum  in  the  upper  portion  of  the 
wound  is  not  divided.  By  interrupted  or  continuous  Lembert  sutuies 
of  linen  the  anterior  gastric  wall  is  sutured  to  the  parietal  peritoneum 
of  the  epigastric  region.  The  sutures  should  be  inserted  near  the 
lesser  curvature  of  the  stomach,  and  should  include  not  only  the 
peritoneum  of  the  abdominal  wall  but  also  the  muscle  and  overlying 
fascia.  They  should  not,  however,  pass  through  the  skin,  as  it  is 
desirable  that  they  should  remain  permanently. 

(2)  Beyea's  Method  (1899).  Interrupted  sutures  of  hnen  are 
passed  through  the  gastro-hepatic  omentum  from  the  stomach  up  to 
the  under  surface  of  the  liver;  each  suture  picks  up  the  lesser  omentum 
in  four  or  five  places.  As  these  sutures  are  tightened  the  lesser  curva- 
ture of  the  stomach  is  drawn  up  against  the  liver  by  the  puckering  of  the 
gastro-hepatic  omentum.  Care  should  be  taken  not  to  puncture  any 
blood-vessels  in  this  structure. 

Gastrectomy 

Gastrectomy. — The  terminology  employed  by  writers  with  re- 
gard to  excision  of  portions  of  the  stomach  is  not  always  uniform,  and 
unless  the  terms  used  are  clearly  defined  confusion  is  liable  to  arise. 
In  the  present  work  we  employ  the  following  terms  to  designate  the 
operations  denoted  below.  Sphincteredomy:  By  this  we  understand 
the  removal  merely  of  the  pyloric  sphincter,  with  end-to-end  reunion 
of  the  duodenum  and  the  stomach.  It  is  an  operation  which  in  a  few 
rare  instances  has  been  employed  for  benign  fibrous  stenosis  of  the 


348    TECHNIQUE   OF  OPERATIONS  ON  THE   STOMACH  AND   DUODENUM 


pylorus,  in  which  the  pre-pyloric  portion  of  the  stomach  was  healthy. 
Pyloroplasty,  we  think,  would  be  a  less  dangerous  and  quite  as  satis- 
factory an  operation.  By  Pylorectomy  we  mean  removal  of  the  pylorus 
with  its  antrum  (Fig.  7) ;  it  is  a  more  extended  resection  than  sphinc- 
terectomy,  but  less  so  than  partial  gastrectomy,  in  which  latter  opera- 
tion the  entire  lesser  curvature  of  the  stomach  is  removed.     In  general, 

we  mean  by  partial  gastrectomy  an 
operation  which  removes  besides 
the  pylorus,  also  the  neighboring 
part  of  the  stomach  as  far  as  the 
Hartmann  or  Mikulicz  line,  always 
including  the  whole  of  the  lesser 
ctirvature  (Fig.  in).  If  the  gastric 
area  removed  extends  still  further 
towards  the  fundus  along  the 
greater  curvature,  we  speak  of  the 
operation  as  subtotal  gastrectomy 
(Fig.  112);  while  the  term  total 
gastrectomy  is  reserved  for  opera- 
tions which  leave  behind  no  portion 
of  the  stomach,  the  upper  section 
passing  through  the  lower  end  of  the  esophagus,  while  the  lower  section 
of  course  divides  the  duodenum.  Circular  or  cylindrical  gastrectomy 
designates  an  operation  by  which  the  central  portion  of  the  stomach 
is  removed,  neither  the  pylorus  nor  the  fundus  being  included  in  the 
section,  although  the  lines  of  division  extend  from  one  curvature  to 
the  other  and  involve  the  entire  circumference  of  the  stomach  (Fig. 
120);  in  this  operation  the  lumen  of  the  stomach  is  restored  by  an 
end-to-end  anastomosis  (circular  gastrorrhaphy). 
By  gastric  resection  we  understand  removal  of  a 
portion  of  the  stomach  not  including  the  entire 
lumen  of  the  organ;  the  term  plastic  resection  we 
think  therefore  properly  describes  the  operation 
called  gastroplasty  by  Jedlicka  (1904);  since  in 
this  operation,  after  resection  of  a  portion  of  the 
anterior  wall  of  the  stomach,  he  reconstructed 
the  organ  by  a  plastic  operation.  Excision  in 
connection  with  gastric  operations  we  would  limit 
to  the  removal  of  more  or  less  circumscribed  lesions  or  pedunculated 
tumors   attached   to  or  springing  from  the  stomach  (Plate  I,  p.  70). 


Fig.  III. — Diagram  Showing  Various 
Incisions  for  Gastrectomy.  F,  G,  Duodenal 
Section;  AB,  Hartmann  Line ;  AC,  Mikulicz 
Line;  ^Z>,  Mayo  Line;  ^£.  Total  Gastrect- 
omy.    (After  Palerson,  1906.) 


Fig.  112. —  Diagram 
to  Show  Portion  of 
Stomach  Removed  in 
Subtotal  Gastrectomy. 


PYLORECTOMY  349 

As  many  of  these  operations  are  always  atypical  it  is  not  possible 
to  describe  them  in  detail.  It  being  well  appreciated  that  every 
surgeon  of  experience  develops  a  technique  more  or  less  peculiar  to 
himself,  and  that  all  that  can  be  asked  in  a  work  of  this  kind  is  an 
adequate  description  of  certain  typical  operations,  we  have  selected 
the  following  for  discussion:  I.  Pylorectomy,  by  Billroth's  first  method. 
II.  Partial  Gastrectomy,  including  Kocher's  method,  Billroth's  second 
method,  and  Polya's  method.  III.  Total  Gastrectomy.  IV.  Cyl- 
indrical Gastrectomy.     V.  Gastric  Resection. 

The  indications  for  the  employment  of  gastrectomy  have  been 
discussed  in  previous  chapters  (pp.  in,  276). 

P*yIorectomy  by  Billroth's  First  Method. — This  operation  (Fig.  113) 
was  first  performed  by  Pean  in  1879,  then  by  Rydygier  in  1880,  and 
first  successfully  by  Billroth  in  1881. 

Open  the  abdomen  by  an  incision  10  to  12  cm.  long,  close  to  the 
median  line,  through  the  right  rectus  muscle.  Place  sufficient  gauze 
packs  in  the  lower  part  of  the  wound  to  keep  the  small  intestines  and 
transverse  colon  from  protruding.  Identify  the  stomach,  and  doubly 
ligate  the  coronary  artery  on  the  lesser  curvature  at  the  site  selected 
for  the  gastric  section,  and  cut  the  artery  between  the  ligatures. 
Doubly  ligate  the  gastro-epiploic  artery  on  the 
greater  curvature  at  the  other  extremity  of  the 
proposed  section,  and  divide  it  between  the  liga- 
tures. Ligate  in  sections,  by  means  of  an  aneurysm 
needle,  the  gastro-hepatic  and  the  gastro-colic 
omenta,  from  the  line  of  the  proposed  section  in 
the  stomach  to  the  duodenum.  At  the  greater 
curvature  this  row  of  ligatures  should  pass  be- 
tween the  gastro-epiploic  artery  and  the  trans- 
verse colon,  great  care  being  exercised  not  to 
include  the  middle  colic  artery  in  any  of  the  liga-  ^n^otviV^sTul^ol 
tures.  The  lesser  omentum  should  be  ligated  of  Gastrectomy. 
fairly  close  to  the  liver. 

Pass  a  gastrectomy  clamp,  with  rubber  sheathed  blades,  from  the 
greater  to  the  lesser  curvature,  at  the  site  of  the  proposed  section  of 
the  stomach.  Bring  its  points  out  far  enough  beyond  the  lesser 
curvature  to  grasp  firmly  between  the  blades  the  whole  of  the  proposed 
section  of  the  stomach.  Parallel  to  this  first  clamp  pass  a  second  on  the 
pyloric  side  of  the  gastric  section,  about  one  inch  distant  from  the 
first  clamp.  The  latter  clamp  need  not  have  its  blades  covered  with 
rubber.     Pass  a  hot  moist  sterile  gauze  pack  across  the  lesser  peritoneal 


350   TECHNIQUE   OF   OPERATIONS   ON  THE   STOMACH  AND  DUODENUM 

cavity  from  one  cur\ature  of  the  stomach  to  the  other,  immediately 
beneath  the  two  clamps  already  placed.  Then  divide  the  stomach  with 
the  scalpel  or  the  actual  cautery  from  one  curvature  to  the  other,  be- 
tween the  two  clamps,  but  close  to  the  clamp  on  the  pyloric  side  of  the 
section,  so  as  to  leave  enough  tissue  protruding  from  the  rubber  covered 
clamp  to  make  the  application  of  sutures  easy.  Turn  the  pyloric 
portion  of  the  stomach  thus  set  free  over  to  the  patient's  right,  and 
place  sufficient  gauze  behind  the  stomach  and  pylorus  to  protect 
thoroughly  the  lesser  peritoneal  cavity.  Having  thus  mobilized  the 
pyloric  portion  of  the  stomach,  it  will  be  easy  to  detect  the  pyloric 
artery  on  the  lesser  curvature,  and  the  beginning  of  the  right  gastro- 
epiploic artery  on  the  greater,  just  below  the  pylorus.  It  is  not  nec- 
essary to  ligate  the  gastro-duodenal  artery  above  the  pylorus;  to  do  so 
might  impair  the  blood  supply  to  the  descending  duodenum  and  the 
head  of  the  pancreas.  When  the  pyloric  and  right  gastro-epiploic 
arteries  have  been  ligated,  a  rubber  covered  clamp  is  to  be  applied  to 
the  first  part  of  the  duodenum,  and  the  pyloric  part  of  the  proposed 
duodenal  section  is  to  be  guarded  by  another  clamp.  Close  to  this 
latter  the  duodenum  is  next  divided  by  scalpel  or  actual  cautery, 
and  the  diseased  part  of  the  stomach  including  the  pylorus  is 
removed. 

The  gastric  segment  will  now  present  a  much  larger  area  than 
the  duodenal.  Hence  the  surgeon  should  begin  his  through-and- 
through  sutures  at  the  lesser  curvature  of  the  gastric  segment,  and  close 
this  portion  of  the  stomach  from  above  downward  until  the  unsutured 
portion  presents  the  same  calibre  as  does  the  duodenum.  The  latter 
is  then  drawn  across  to  the  gastric  segment  and  united  to  its  unsutured 
portion  first  by  a  posterior  sero-serous  continuous  suture  of  linen;  then 
the  through-and-through  (chromic  gut)  suture  is  resumed,  and  the 
duodenum  united  to  the  stomach  throughout  the  circumference  of  the 
bowel,  great  care  being  exercised  to  secure  accurate  approximation  at 
the  point  where  the  suture  line  of  the  gastric  section  meets  the  gastro- 
duodenal  anastomosis.  This  point  of  junction  is  known  as  the  "deadly 
angle"  from  the  frequency  with  which  leakage  has  occurred  there 
(Fig.  113).  When  the  duodenum  and  stomach  are  thus  united  securely 
by  a  through-and-through  suture,  the  gastric  and  duodenal  clamps  are 
removed,  and  any  bleeding  points  reinforced  by  specially  inserted 
sutures.  Finally  the  entire  line  of  sutures,  both  that  of  the  gastric 
segment  and  that  of  the  anastomosis,  should  be  inverted  by  a  continuous 
sero-serous  suture.  The  gauze  packs  may  now  be  removed ;  the  remains 
of  the  gastro-hepatic  and  gastrocolic  omenta  are  stitched  to  the  upper 


PARTIAL    GASTRECTOMY 


351 


and  lower  portions  of  the  anastomosis,  and  the  abdominal  wound  is 
closed. 

Partial  Gastrectomy,  (j)  Kocher's  Method  (1891) . — In  this  opera- 
tion the  distal  segment  of  the  divided  duodenum  is  implanted  (termino- 
lateral  anastomosis)  into  the  posterior  wall  of  the  stomach,  a  little  to 
the  left  of  the  gastric  section  which  is  entirely  closed  (Fig.  114).  Kocher 
used  crushing  forceps  in  this  operation,  instead  of  the  rubber  covered 
clamps  employed  by  most  surgeons;  he  made  the  section  of  the  stomach 
close  to  the  crushing  forceps,  and  as  a  consequence  it  was  necessary  for 
the  through-and-through  sutures  to  be  applied 
on  the  cardiac  side  of  the  crushing  forceps. 
Then  when  these  forceps  are  removed,  the 
projecting  tissue  is  trimmed  close  to  the  line 
of  the  through-and-through  sutures,  and  the 
latter  are  inverted  by  a  running  sero-serous 
suture.  The  following  description  of  the  oper- 
ation is  taken  from  the  English  translation  by 
Stiles  of  Kocher's  Operative  Surgery  (London, 
1903,  p.  215). 

"After  ascertaining  exactly  the  limits  of  the 
tumor  and  the  mobihty  and  the  possibility  of  p^^  114.  — Diagram  of 
separating  glands,  the  lesser  omentum  and  the  Kocher's  Method  of  Gas- 
gastrocolic    hgament    are    perforated    at    the 

margin  of  the  new  growth  towards  the  fundus  of  the  stomach,  and  two 
large  pressure-forceps  are  applied  quite  close  to  each  other,  and  closed  as 
firmly  as  possible.  After  gauze  pads  have  been  placed  beneath  the  for- 
ceps (the  aseptic  protecting  pads  have  previously  been  placed  round  the 
parts  outside  the  abdomen)  the  stomach  is  cut  across  between  the  two 
clamps,  close  up  to  the  one  to  the  right.  According  to  Hartmann's 
rule,  and  on  the  grounds  of  Cuneo's  observations,  the  clamps  must  be 
applied  to  the  lesser  curvature  as  high  up  and  as  much  to  the  left  as 
possible;  and  in  order  that  the  glands  that  accompany  the  coronary 
vessels  may  at  the  same  time  be  removed,  it  appears  to  us  advisable  to 
double  ligature  and  cut  across  the  coronary  artery  above  the  point 
where  the  section  is  to  be  made.  By  dividing  bloodlessly  the  small 
omentum  above  the  glands  the  divided  stomach  is  rendered  so  movable 
that  it  can  be  turned  over  to  the  right  side. 

"Hartmann  places  value  on  the  last  procedure  because  the  fatty 
tissue  and  glands  can  then  be  followed  up  along  the  lesser  curvature 
and  can  be  included  in  the  removal  as  far  as  the  origin  of  the  pyloric 
and  the  gastroduodenal  branches  of  the  hepatic  artery.     The  latter 


352    TECHNIQUE   OF  OPERATIONS   ON   THE   STOMACH  AND  DUODENUM 

vessel  is  carefully  avoided,  while  the  two  hrst  named  are  ligatured. 
After  throwing  the  stomach  over  towards  the  right  margin  of  the 
wound,  one  sees  quite  well  the  gastroduodenal  artery  running  down- 
wards in  the  groove  between  the  duodenum  and  pancreas.  In  this 
way  no  bleeding  should  occur  in  detaching  the  chain  of  glands  which 
accompany  this  artery  along  the  above-mentioned  groove.  We  can 
manage  quite  well  without  ligaturing  the  artery.  Throwing  the 
stomach  over  to  the  right  edge  of  the  wound  has  the  advantge  that 
by  drawing  upon  it  the  duodenum  is  rendered  quite  accessible  from 
behind,  so  that  the  limits  of  the  new  growth  can  be  ascertained  with 
certainty,  and  one  can  determine  if  the  duodenum  be  long  enough 
and  movable  enough  to  enable  one  to  perform  gastroduodenostomy. 
When  this  is  the  case,  two  small  pressure-forceps  are  now  applied  to 
the  duodenum,  which  is  cut  across  between  them  with  the  knife  close 
up  to  the  pair  farther  removed  from  the  stomach,  a  small  pad  of  gauze 
having  previously  been  placed  under  the  part.  The  cut  edges  are  then 
carefully  and  thoroughly  cleansed. 

"The  opening  can  now  be  made  into  the  stomach  before  closing  it 
with  sutures,  because  the  forceps  in  position  afford  a  very  good  sup- 
port. A  pair  of  clamp-forceps  is  applied  to  the  duodenum  and  the 
accompanying  vessels,  and  the  crushing-forceps  are  removed.  The 
fingers  of  the  assistant  can  now  grasp  the  stomach  so  that  the  anterior 
wall  is  pressed  against  the  posterior  wall  at  the  place  where  the  in- 
cision has  been  made;  or  a  pair  of  clamp-forceps  may  be  applied  to 
the  stomach  after  it  has  been  closed  by  suturing  and  before  the  in- 
cision is  made  for  anastomosis  with  the  duodenum. 

"A  continuous  mattress  suture,  after  the  manner  of  a  half  Gely's 
suture,  is  carried  behind  the  crushing-forceps  (which  has  not  been 
removed  from  the  stomach) ;  only  the  commencement  is  knotted, 
and  by  pulling  on  the  two  ends  reliable  closure  is  effected.  If  the 
crushing-forceps  are  not  strong  enough  to  compress  the  tissues  so  that 
they  are  like  thin  dry  paper,  it  is  desirable  that  every  projecting  portion 
of  mucous  membrane  and  muscular  pulp  should  be  clipped  away 
with  scissors,  but  this  is  unnecessary  if  sufiicientl}'-  powerful  com- 
pression (crushing)  forceps  are  employed.  With  the  ends  of  the 
suture  held  taut,  a  continuous  glover's  suture  is  rapidly  applied  over  it 
so  as  to  fix  each  loop,  and  the  closure  is  completed  by  inverting  both 
by  a  continuous  serous  suture. 

"The  stomach  and  duodenum  are  now  clamped  at  some  distance 
from  the  place  where  they  ha\-e  been  opened,  or  are  to  be  opened,  and 
the  crushing  forceps  are  removed  from  the  duodenum.     Escape    of 


PARTIAL   GASTRECTOMY  353 

the  contents  being  carefully  prevented,  an  incision  is  made  into  the 
posterior  wall  of  the  stomach  near  the  greater  curvature  at  a  distance  of 
3  cm.  (about  one  inch  and  a  quarter)  from,  and  parallel  to,  the  sutures 
which  close  it,  at  first  merely  through  the  serosa,  for  a  length  equal  to 
the  breadth  of  the  duodenum.  The  posterior  segment  of  the  circular 
suture  is  now  applied.  The  wall  of  the  stomach  is  then  completely 
cut  through  and  a  continuous  suture,  passing  through  all  the  coats,  is 
applied  so  as  to  unite  the  posterior  edges  of  the  opening  in  the  stomach 
and  duodenum.  A  third  continuous  suture  is  applied  so  as  to  unite 
the  two  mucous  edges.  The  anterior  edges  are  now  united  by  a  con- 
tinuous suture  which  passes  through  all  the  coats,  and  is  knotted  at 
each  end  to  the  posterior  suture.  The  clamp-forceps,  if  such  have 
been  employed,  are  removed,  and  lastly,  the  anterior  serous  suture  is 
applied  and  knotted  at  each  end  with  the  posterior  serous  suture." 

Remarks. — The  technique  employed  by  Kocher,  as  is  seen  from 
the  above  description,  coincides  with  that  preferred  by  Hartmann, 
in  that  the  stomach  is  divided  before  the  duodenum,  is  then  turned 
to  the  patient's  right,  and  the  duodenal  section  made  after  clearing 
the  glands  away  from  along  the  gastro-duodenal  artery.  The  par- 
ticular part  of  the  operation  by  virtue  of  which  Kocher's  name  has 
been  attached  to  it,  consists  in  the  implantation  of  the  duodenum  into 
the  posterior  wall  of  the  stomach.  If  the  removal  of  the  stomach  has 
been  at  all  extensive,  it  is  very  likely  that  it  will  be  impossible  to  bring 
the  duodenum  and  stomach  into  apposition,  even  after  mobilizing 
the  duodenum.  In  such  circumstances  gastro-jejunostomy  should  be 
done. 

(2)  Billroth's  Second  Method. — This  method,  in  which  the  opera- 
tion is  terminated  by  a  gastro-jejunostomy,  is  that  which  is  commonly 
performed.  Usually  the  anastomosis  should  be  made  in  the  posterior 
wall  of  the  stomach;  but  if  the  patient's  condition  is  bad,  or  if  the 
remaining  portion  of  the  stomach  is  very  small,  anterior  gastro-jeju- 
nostomy, as  done  by  Billroth  himself,  may  be  adopted.  The  use 
of  a  Murphy  button  may  hasten  the  procedure  in  desperate  cases. 

The  technique  habitually  employed  is  the  following : 

After  exposing  the  stomach,  the  coronary  artery  is  identified, 
doubly  hgated  and  divided,  close  to  the  cardiac  orifice  of  the  stomach. 
The  finger  is  passed  through  the  gastro-hepatic  omentum  into  the 
lesser  peritoneal  cavity,  and  the  gastro-hepatic  omentum  is  ligated  in 
sections,  fairly  close  to  the  transverse  fissure  of  the  liver.  By  cutting 
through  the  gastro-hepatic  omentum,  the  surgeon  reaches  the  pyloric 
artery,  which  is  doubly  hgated  and  cut.     The  finger  is  then  passed 

23 


354    TECHNIQUE   OF   OPERATIONS  ON  THE   STOMACH  AND  DUODENUM 

down  behind  the  pylorus,  and  the  right  gastro-epiploic  artery  is  identi- 
fied below  the  pylorus;  this  artery  is  ligated  in  two  places,  and  cut 
between  the  ligatures.  Hemostatic  forceps  are  then  applied  to  the 
gastrocolic  omentum,  and  as  they  are  applied  this  structure  is  divided 
between  them,  beginning  at  the  pylorus  and  passing  along  the  upper 
border  of  the  transverse  colon  until  the  point  is  reached  at  which  it 
is  proposed  to  divide  the  stomach.     This  point  should  be  5  cm.  to 


Fig.  115. — Partial  Gastrectomy:  Di*vision  of  Gastro-colic  Omentum. 


the  left  of  the  visible  malignant  growth.  When  this  point  has  been 
reached,  the  left  gastroepiploic  artery  is  Hgated  just  to  the  left  of 
the  proposed  gastric  incision.  In  placing  the  hemostats  on  the  gastro- 
colic omentum,  great  care  is  to  be  taken  to  avoid  the  middle  colic 
artery  and  its  branches  (Fig.  115). 

The  portion  of  stomach  to  be  removed  is  now  completely  freed 
along  its  curvatures,  and  remains  attached  only  to  the  duodenum  and 


PARTIAL    GASTRECTOMY 


355 


the  body  of  the  stomach.  The  lesser  peritoneal  cavity  can  now  be 
protected  thoroughly  by  sterile  gauze  compresses.  A  clamp  with 
rubber-covered  blades  is  now  applied  to  the  duodenum  about  2.5  cm. 
beyond  the  portion  visibly  diseased,  and  an  ordinary  clamp  is  applied 
just  to  the  pyloric  side  of  the  first  clamp.  The  duodenum  is  then 
divided  between  the  two.  The  entire  portion  of  the  stomach  to  be 
excised  can  now  be  turned  to  the  patient's  left.  The  duodenal 
stump  is  closed  first  by  a  through-and-through  chromic  catgut  suture; 
before  the  occluding  clamp  is  removed  a  purse-string  suture  of  linen 


Fig.  116. — Partial  Gastrectomy  r  The  Duodenum  has  been  Divided,  and  the  Clamps  are  in 
Place  for  the  Gastric  Section. 

is  applied;  the  clamp  is  then  removed,  and  by  catching  the  duodenal 
wall  in  two  places  with  dissecting  forceps,  the  sutured  end  of  the 
duodenum  is  inverted  and  the  purse-string  suture  is  drawn  tight 
and  tied.  Sometimes  a  few  additional  Lembert  sutures  of  linen  are 
inserted  to  re-inforce  those  previously  placed.  As  the  duodenum  is 
divided  where  part  of  its  wall  is  retroperitoneal,  it  is  very  important  to 
suture  it  accurately;  but  usually  the  through-and-through  suture  and 
the  purse-string  suture  are  all  that  is  necessary.  The  gastro-colic 
omentum  is  then  ligated,  and  the  hemostatic  forceps  removed. 


,3S6   TECHNIQUE  OF  OPERATIONS   ON   THE   STOMACH  AND  DUODENUM 

Rubber-covered  gastrectomy  clamps  are  then  applied  across  the 
stomach  from  the  greater  to  the  lesser  curvature,  at  least  5  cm.  to  the 
left  of  the  visible  maHgnant  growth  (Fig.  116).  Clamps  with  a  screw 
lock  at  the  end  of  the  blades,  as  in  Kocher's  clamps,  are  safest.  The 
entire  lesser  curvature  is  always  removed,  but  the  line  of  the  section 
passing  from  that  point  to  the  greater  curvature  varies  with  the  extent  of 
the  tumor.  About  2  cm.  to  thepatient's  right  of  this  occluding  clamp,  an 
ordinary  forceps  is  applied,  and  the  stomach  is  divided  between  the  two 
with   the   actual   cautery.     The   excised   portion   being   removed,    a 


Fig.   1 1 7. — Partial    Gastrectomy: 


Through-and-through    Sutures    being    Applied  to  the 
Gastric  Section. 


through-and-through  suture  of  chromic  catgut  is  inserted  through  the 
margins  of  the  gastric  walls  which  protrude  from  between  the  blades 
of  the  rubber-covered  clamp  (Fig.  117).  It  is  well  to  grasp  these 
margins  at  one  or  more  points  with  forceps  to  prevent  their  retracting. 
When  the  through-and-through  sutures  have  been  completed,  the 
clamp  is  removed,  and  a  continuous  sero-serous  suture  is  applied,  bury- 
ing the  first  row,  and  carefully  rc-inforcing  any  points  that  tend  to 
bleed  (Fig.  118). 

The   transverse  colon  is  then  drawn  out  of  the  wound,  and  the 


PARTIAL   GASTRECTOMY 


357 


posterior  gastric  wall  is  exposed  by  opening  the  transverse  mesocolon. 
A  posterior  gastro-jejunostomy  is  then  done  by  the  usual  technique, 
as  described  at  page  338,  and  as  indicated  diagrammatically  in  Fig.  118. 
Finally,  after  suturing  the  margins  of  the  opening  in  the  transverse 
mesocolon  to  the  gastric  wall,  and  replacing  the  newly  formed  anas- 
tomosis within  the  abdomen,  the  great  omentum  is  drawn  up  to  cover 
the  space  left  by  the  removal  of  the  stomach,  and  the  abdominal  wound 
is  closed. 


Fig.  118. — Partial  Gastrectomy:  Sero-serous  Sutures  being  Applied  to  the  Stomach. 

(3)  Polya's  Method  (191 1).— In  this  method  the  opened  end  of  the 
stomach  left  after  removal  of  the  diseased  portion  is  implanted  into  the 
side  of  the  jejunum,  which  is  drawn  up  through  the  transverse  meso- 
colon.'    The  stomach  is  exposed  in  the  usual  way,  the  gastro-hepatic 

'Mikulicz  stated  as  early  as  1898  that  he  preferred  this  method  of  completing  the  opera- 
tion of  gastrectomy;  but  credit  is  undoubtedly  due  to  Polya,  and  in  this  country  to  Mayo, 
for  standardizing  and  popularizing  the  procedure. 


3S8    TECHNIQUE   OF   OPERATIONS   ON  THE   STOMACH  AND   DUODENUM 

and  gastro-colic  omenta  are  divided,  the  duodenum  sectioned  and  closed 
and  the  stomach  is  turned  to  the  patient's  left.  An  antero-posterior 
incision  is  then  made  in  an  avascular  area  of  the  transverse  meso-colon 
from  its  upper  surface,  and  the  first  coil  of  jejunum  is  drawn  up  from  below 
through  this  opening  (Fig.  119).     It  is  ne.\'t  attached,  by  a  continuous 


Fig.  119. — Polya's  Method  of  Gastrectomy:  After  Section  and  Closure  of  the  Duode- 
num, the  Stomach  is  Turned  Upward  to  the  Patient's  Lett,  Fully  Exposing  Its  Posterior 
Wall;  the  Transverse  Mesocolon  is  Opened,  the  First  Coil  of  the  Jejunum  is  DrawnThrough 
It,  and  Anastomosed  with  the  Sectioned  End  of  the  Stomach,  as  Indicated  in  the  Smaller 
Drawing.  From  a  Dissection  by  the  Junior  Author  in  the  Laboratory  of  Operative 
Surgery,  University  of  Pennsylvania. 

sero-serous  suture  of  linen,  to  the  posterior  wall  of  the  stomach,  well 
beyond  the  diseased  area,  in  such  a  way  that  the  proximal  portion  of 
jejMnum  corresponds  to  the  lesser  curvature,  and  the  distal  portion  of 
the  jejunum  to  the  greater  curvature  of  the  stomach.     Before  cutting 


SUBTOTAL   GASTRECTOMY  359 

away  the  stomach  an  occluding  clamp  should  be  applied  on  each  side 
of  the  proposed  section.  The  jejunum  also  is  clamped  before  it  is 
opened  (Fig.  119),  along  its  antimesenteric  border  for  a  distance  nearly 
equal  to  the  opened  end  of  the  stomach,  which  is  to  be  implanted  into 
the  side  of  the  jejunum.  The  anastomosis  between  stomach  and 
jejunum  is  then  completed  in  the  ordinary  manner,  the  clamps  are 
removed,  the  margins  of  the  opening  in  the  mesocolon  are  sutured  to 
the  stomach  above  the  anastomosis,  and  the  abdominal  wound  is 
closed  in  the  usual  way. 

This  is  an  excellent  operation,  presenting  distinct  advantages  not 
possessed  by  Billroth's  second  method.  Time  is  saved  in  that  a 
separate  anastomosis  is  not  necessary  after  the  cut  end  of  the  stomach 
has  been  disposed  of;  less  exposure  is  required  of  the  abdominal  con- 
tents as  it  is  not  necessary  to  deliver  the  great  omentum  and  transverse 
colon  from  the  abdominal  incision  in  order  to  expose  the  jejunum  and 
do  a  posterior  gastrojejunostomy;  and  the  restoration  of  the  gastro- 
intestinal canal  is  much  simpler  and  easier  in  cases  of  extensive  removal 
of  the  stomach. 

In  191 7  Mayo  and  Balfour  adopted  an  antecolic  anastomosis 
between  jejunum  and  stomach  by  Polya's  technique.  This  presents 
certain  obvious  advantages  in  cases  of  subtotal  gastrectomy.  They 
prefer  to  close  the  sectioned  end  of  the  stomach  for  a  convenient  dis- 
tance upward  from  the  greater  curvature,  thus  making  the  anastomotic 
opening  into  the  jejunum  comparatively  small  and  close  to  the  lesser 
curvature  of  the  stomach. 

Subtotal  gastrectomy  differs  from  partial  gastrectomy  only  in 
the  extent  of  the  stomach  removed.  A  precisely  .similar  technique 
may  be  employed.  In  some  cases,  however,  there  will  be  so  small  a 
portion  of  the  cardia  left  that  only  an  anterior  gastro-jejunostomy  can 
be  done.  As  already  remarked,  Mayo  and  Balfour's  modification 
(19 1 7)  of  Polya's  technique  is  suitable  for  such  cases. 

Remarks. — It  is  seen  that  the  technique  of  partial  gastrectomy  as 
above  given  is  practically  identical  with  that  described  by  Mayo 
in  1904.  Although  the  technique  of  Hartmann,  in  which  the  gastric 
section  is  made  first,  and  the  tumor  then  turned  to  the  patient's  right, 
before  dividing  the  duodenum,  presents  the  undoubted  advantage  of 
approaching  the  dangerous  retro-pyloric  region  in  an  open  and  strictly 
anatomical  way,  yet  it  has  the  disadvantage,  as  pointed  out  by  Mayo, 
of  being  less  easy  of  accomplishment  than  the  method  in  which  the 
duodenum  is  divided  first;  because  the  line  of  proposed  section  of  the 
stomach  is  frequently  difficult  of  access  until  the  stomach  is  mobilized 


360   TECHNIQUE  OF  OPERATIONS   ON  THE   STOMACH  AND  DUODENUM 

by  section  of  the  duodenum.  We  would  point  out,  moreover,  that 
Mayo's  operation  has  the  distinct  advantage  that  the  occluding  clamps 
are  not  applied  to  the  stomach  until  the  last  possible  moment,  and  that 
they  are  kept  in  place  for  the  very  shortest  possible  time — in  fact,  only 
until  it  is  possible  to  insert  the  through-and-through  sutures.  There 
is  thus  scarcely  any  risk  of  interference  with  the  vascular  supply  of  the 
sutured  edges. 

Total  Gastrectomy. — In  rare  cases  after  the  abdomen  has  been 
opened  it  may  be  found  that  the  disease  has  invaded  so  great  an  area 
of  the  stomach  as  to  render  its  entire  removal  desirable,  while  at  the 
same  time  no  secondary  growths  or  adhesions  exist  which  will  render 
such  an  operation  impracticable. 

The  operation  should  proceed  along  the  same  lines  as  partial 
gastrectomy,  until  the  duodenum  has  been  divided.  It  is  then  to  be 
determined  whether  the  duodenum  can  be  made  to  reach  the  esoph- 
agus without  undue  tension.  Mobilization  of  the  duodenum,  as  in 
operations  on  the  retro-duodenal  portion  of  the  common  bile  duct, 
may  render  this  possible.  If  the  duodenum  can  be  made  to  reach  the 
esophagus,  it  should  be  attached  to  the  latter  by  a  primary  posterior 
row  of  sutures  before  the  cardiac  orifice  of  the  stomach  is  divided. 
Exposure  of  the  cardia  as  in  Lambert's  method  (Figs.  44,  45)  may  facili- 
tate the  subsequent  steps.  Then  the  cardia  is  clamped,  divided  above 
the  clamp,  and  the  union  of  the  duodenum  to  the  esophagus  completed, 
an  end-to-end  anastomosis  being  performed  in  the  usual  way.  If  the 
duodenum  cannot  be  made  to  reach  the  esophagus,  a  coil  of  the  upper 
jejunum,  provided  with  a  long  mesentery,  should  be  selected;  the 
jejunum  should  be  divided  completely  across,  its  distal  end  being  united 
to  the  esophagus  by  circular  (end-to-end)  anastomosis,  and  the  proximal 
end  being  implanted  into  the  distal  segment  at  a  convenient  distance 
below  the  esophago-jejunal  anastomosis.  The  jejunum  should  be 
united  to  the  esophagus  by  the  trans-mesocolic  route  if  possible.  The 
Murphy  button  may  be  employed  if  accurate  suturing  is  impossible. 

Should  the  surgeon  be  so  heedless  as  to  remove  the  entire  stomach 
before  determining  whether  any  portion  of  the  intestinal  tract  can  be 
anastomosed  to  the  esophagus,  he  should  insert  a  tube  into  the  divided 
end  of  the  duodenum  and  suture  the  latter  into  the  abdominal  wound ; 
should  this  be  impossible,  jejunostomy  may  be  a  last  resort. 

It  might  be  possible  to  connect  the  esophagus  and  duodenum  by 
an  excluded  loop  of  the  jejunum,  transplanted  through  the  transverse 
mesocolon,  somewhat  after  the  manner  of  Herzen's  operation  of  gas- 
trostomy (p.  324). 


CYLINDRICAL   GASTRECTOMY  36 1 

Vassalo  reported  (1906)  a  case  of  total  gastrectomy  in  which  the 
entire  time  consumed  m  the  operation  was  only  thirty-eight  minutes. 

Cylindrical  Gastrectomy 

Cylindrical  Gastrectomy. — This  operation  (known  also  as  "Sleeve- 
resection")  is  suitable  only  for  benign  lesions  occupying  the  middle  zone 
of  the  stomach  (Figs.  1 20  to  1 23) .  If  there  exist  an  ulcerated  area  which 
does  not  obstruct  either  orifice  of  the  stomach,  as  is  the  case  with 
some  ulcers  along  the  lesser  curvature;  and  if  some  form  of  radical 
operation  is  to  be  preferred  to  gastro-jejunostomy,  then  a  cylindrical 


Fig.   120. — Cylindrical  Gastrectomy,  the  Clamps  in  Place. 

gastrectomy  frequently  will  be  simpler  and  easier  of  accomplishment 
than  resection  of  a  V-shaped  area  from  the  lesser  curvature.  In 
some  cases  of  hour-glass  stomach  cylindrical  gastrectomy  may  be  of 
benefit. 

We  entirely  agree  with  Leriche  (1907),  however,  in  his  dictum  that 
cylindrical  gastrectomy  is  absolutely  contra-indicated  if  there  are 
enlarged  glands  in  the  gastro-hepatic  omentum ;  but  we  would  go  further, 
and  prohibit  its  employment  in  coery  case  of  malignant  disease,  because 
under  such  circumstances  the  entire  lesser  curvature  should  be  re- 
moved. Leriche,  who  is  a  supporter  of  excision  of  benign  lesions  in 
general,  makes  the  bold  but  possibly  significant  statement  that  if  this 
operation  were  more  often  done  for  non-stenosing  cancer,  more  cases 
of  progressive  pernicious  anemia  would  be  cured. 

The  operation  may  be  performed  thus:  After  exposing  the  stomach 
and  ligating  the  main   arteries  at  the  extremities  of  the  proposed 


362    TECHNIQUE   OF  OPERATIONS   ON  THE   STOMACH  AND  DUODENUM 

sections,  the  gastro-colic  and  gastro-hepatic  omenta  are  next  ligated, 
and  divided.     Then  two  pairs  of  rubber-covered  clamps  are  applied, 


Pig.  121. — Cylindrical  Gastrectomy;  After  Removal  of  the  Diseased  Area,  the  Portions  of 
the  Stomach  Remaining  are  United  by  End-to-end  Anastomosis. 

including  between  them  the  portion  of  stomach  to  be  removed,  which 
should  be  emptied  as  completely  as  possible  before  tightening  the 


Fig.  122. — Cylindrical  Gastrectomy:    The    Through-and-through  Suture  for  End-to-end 

Anastomosis  being  Applied. 

clamps.     The  diseased  portion  of  the  stomach  is  then  cut  away,  and 
the  divided  surfaces  of  the  stomach  united  by  circular  gastrorrhaphy 


GASTRIC   RESECTION  363 

(end-to-end  anastomosis).  Leriche  calls  attention  to  the  advantages 
of  commencing  and  terminating  the  continuous  sutures,  not  at  one  of 
the  curvatures  of  the  stomach,  where  the  peritoneal  coat  is  defective, 
but  at  some  convenient  point  on  the  anterior  gastric  wall.  If  the  two 
portions  of  the  stomach  do  not  meet  with  the  utmost  facility,  that  is 
to  say,  if  there  be  the  very  least  tension  on  the  sutures  anywhere,  it 
will  be  possible  to  overcome  this  by  mobilization  of  the  duodenum.     In 


"^ 


Pig.    123. — Cylindrical  Gastrectomy.      The  Operation  Completed. 

some  cases  it  may  seem  better  to  terminate  the  operation  as  in  exclusion 
of  the  pylorus,  by  closing  both  gastric  segments  and  doing  a  separate 
gastro-jejunostomy. 

Hartmann  (1914)  objected  to  cylindrical  gastrectomy  that  it 
interfered  markedly  with  peristalsis;  but  G.  D.  Stewart  and  Barber 
(1916)  concluded  that  there  was  not  much  if  any  delay  in  evacuation 
of  such  stomachs;  and  that  in  these  respects  it  was  a  more  satisfactory 
operation  than  gastric  resection. 

Gastric  Resection 

Gastric  Resection. — Removal  of  a  wedge-shaped  area  from  the 
lesser  curvature  of  the  stomach  may  be  accomplished  by  applying 
rubber-covered  clamps  outside  of  the  proposed  lines  of  section,  after 
tying  off  the  gastro-hepatic  omentum.  The  wounds  left  may  then 
be  sutured  the  one  to  the  other,  thus  approximating  the  cardiac  and 
pyloric  orifices.  This  mode  of  reunion  may  prove  difficult  or  even 
impossible;  under  which  circumstances  a  complicated  form  of  plastic 
operation  may  have  to  be  undertaken.     This   operation,   therefore. 


364  TECHNIQUE   OF  OPERATIONS    ON  THE   STOMACH  AND  DUODENUM 

is  not  one  to  be  lightly  undertaken;  indeed  we  cannot  see  that  it  pre- 
sents any  advantages  over  cylindrical  gastrectomy. 

In  many  cases  resection  of  a  callous  ulcer  must  be  atypical;  but 
always,  in  closing  the  defect,  an  effort  should  be  made  not  to  cause 
stenosis  of  the  gastric  canal,  but  rather  to  enlarge  it  by  suturing  the 
defect  transversely  to  the  long  axis  of  the  stomach. 

Jedlicka  adopted  (1904)  a  form  of  plastic  resection  of  the  stomach 
which  he  calls  gastroplasty.  By  this  operation,  after  removing  the 
diseased  portion  of  the  lesser  curvature  and  of  the  anterior  or  posterior 
walls  of  the  stomach,  he  reconstructs  the  natural  contour  of  the  stomach 
by  the  method  of  sliding  flaps.  In  one  case  the  operation  took  two 
hours  and  a  quarter. 

Excision  of  Ulcers  on  the  Posterior  Wall. — If  the  ulcer  is  close  to 
either  curvature,  it  usually  may  be  exposed  through  the  corresponding 
omentum  (gastro-hepatic  or  gastro-coHc). 

If  not  readily  accessible  in  this  way,  the  surgeon  may  adopt  the 
inter-colo-epiploic  route,  as  it  is  called,  detaching  bloodlessly  the  great 
omentum  from  the  transverse  colon,  displacing  the  former  upward  and 
the  latter  downward.  This  route,  which  was  particularly  studied  by 
Lardennois  and  Okinczyc  (191 3)  in  connection  with  colectomy,  was 
adopted  by  Pauchet  (1916)  for  repair  of  gunshot  wounds  involving  the 
the  posterior  gastric  wall,  and  for  exploration  of  the  posterior  wall  in 
cases  of  suspected  ulcer  and  for  excision  of  ulcers  adherent  to  the  pan- 
creas. Fig.  II  indicates  what  ample  exposure  may  be  gained,  not  only 
of  the  body  of  the  stomach,  but  even  of  the  posterior  surface  of  the 
pylorus  and  duodenum.  The  bloodless  area  between  the  epiploic 
branches  of  the  gastro-epiploic  arteries  above  and  the  bloodvessels  of 
the  transverse  mesocolon  below  is  best  identified  by  pulling  the  omen- 
tum out  of  the  wound  until  the  transverse  colon  becomes  taut;  then  the 
dissection  commences  toward  the  flexures  of  the  colon  and  approaches 
the  centre  from  both  sides. 

Transgastric  Excision. — It  may  be  simpler  to  open  the  anterior  wall 
of  the  stomach  by  an  ample  incision  and  to  excise  the  ulcer  from 
within,  as  indicated  in  Fig.  124.  This  plan  was  adopted  by  Pilcher 
in  1907,  and  popularized  by  Mayo  in  1910.  After  repair  of  the  defect 
from  the  interior  of  the  stomach  by  continuous  suture  of  chromic  gut, 
the  serous  surface  of  the  wound  in  the  posterior  wall  may  be  exposed 
through  a  comparatively  small  opening  in  the  gastro-colic  omentimi  by 
the  aid  of  the  fingers  in  the  cavity  of  the  stomach;  and  a  reinforcing 
suture  of  linen  applied.  Mayo  considers  a  single  row  of  through-and- 
through  sutures,  apphed  from  the  mucous  surface,  sufficient  in  most 


TRANSGASTRIC    EXCISION 


365 


Fig.  124. — Transgastric  Excision  of  an  Ulcer  on  the  Posterior  Wall  of  the  Stomach:  In 
the  Centre  the  Ulcer  is  Exposed;  Above  it  is  Shown  Excised,  and  Sutured  from  Within; 
Below  a  Reinforcing  Sero-serous  Suture  is  Being  Applied  after  Exposing  the  Posterior 
Wall  Through  the  Gastrocolic  Omentum.  From  a  Dissection  by  the  Junior  Author  in 
the  Laboratory  of  Operative  Surgery,  University  of  Pennsylvania. 


366  TECHNIQUE  OF  OPERATIONS  ON  THE  STOMACH  AND  DUODENUM 

cases.     Then  the  opening  in  the  stomach's  anterior  wall  is  closed  in  the 
usual  manner. 

Resection  of  the  cardia,  founded  on  the  advances  in  thoracic  surgery 
inaugurated  by  Sauerbruch  (1905)  and  by  Brauer,  was  accomplished 
in  one  case  of  carcinoma  by  Wendel  (1907)  with  the  use  of  Brauer's 
positive  pressure  air  chamber  around  the  patient's  head.  He  operated 
on  Sept.  6,  1906,  making  an  incision  16  cm.  long  in  the  sixth  left  costal 
interspace,  cutting  through  the  seventh  costal  cartilage.  Some  adhe- 
sions between  the  lung  and  pleura  were  separated,  and  the  lung  was 
excluded  from  the  field  of  operation  by  the  use  of  gauze  packs.  The 
vagi  were  then  freed  without  difficulty,  the  lower  end  of  the  esophagus 
isolated,  and  gauze  was  passed  behind  it.  The  esophagus  was  then 
freed  from  the  diaphragm.  This  work  was  absolutely  in  the  dark,  and 
accomplished  only  by  the  sense  of  touch;  it  was  very  difficult;  there  was 
free  arterial  bleeding,  and  the  bleeding  points  were  very  difficult  to 
ligate.  The  time  consumed  was  now  an  hour  and  a  half.  It  was  found 
impossible  to  do  an  anastomosis  between  the  esophagus  and  thestomach 
to  one  side  of  the  tumor,  so  resection  was  undertaken.  The  tumor 
could  be  drawn  out  through  the  diaphragm  and  across  the  pleural 
cavity,  even  to  the  thoracic  wound.  It  was  surrounded  by  gauze 
packs.  The  vagi  were  found  enterLn.g  the  tumor  and  could  not  be 
dissected  free  lower  down.  They  were  therefore  cut  oft"  i  cm.  from  their 
point  of  entrance  into  the  tumor.  The  esophagus  was  next  divided ,  and 
its  end  closed  by  sutures.  Before  this  was  done,  however,  the  male 
half  of  a  Murphy  button  was  inserted  into  the  esophagus,  and  later  was 
liberated  by  making  a  slit  in  the  side  of  the  latter.  The  gastric  incision 
included  practically  all  of  the  lesser  curvature,  and  a  good  deal  of  the 
fundus  of  the  stomach.  The  female  half  of  the  button  was  passed  into 
the  cavity  of  the  stomach  through  the  gastric  wound,  which  was  then 
completely  closed,  the  shank  of  the  button  being  made  to  protrude  at 
another  point  of  the  gastric  wall,  where  it  was  exposed  by  a  puncture, 
and  the  two  halves  of  the  button  approximated.  Finally  the  margins 
of  the  diaphragmatic  incision  were  sutured  to  the  stomach  below  the 
anastomosis,  and  the  intercostal  wound  was  closed,  with  a  strip  of  gauze 
for  drainage.  The  time  of  the  entire  operation  was  somewhat  over  two 
hours.  Although  the  patient  reacted  well,  death  occurred  suddenly  the 
next  morning  from  secondary  hemorrhage.  The  bleeding  was  found  to 
come  not  from  the  line  of  sutures,  but  probably  from  one  of  the  vessels 
which  had  been  so  difficult  to  ligate. 

A  similar  operation  had  been  done  previously,  and  with  success, 
several  times  on  dogs,  by  Sauerbruch  (1905)  and  by  Sencert  (1905)  and 


EXCISION   OF    THE   DUODENUM  367 

it  had  been  attempted  in  two  cases  by  Sauerbruch  (1906)  on  man,  but 
the  patient  in  whom  resection  was  attempted  died  on  the  table,  and 
in  the  other  the  tumor  was  found  to  be  inoperable,  and  an  esophago- 
gastric anastomosis  was  done,  the  patient  dying  in  24  hours. 

Wiener,  in  a  patient  with  carcinoma  of  the  lesser  curvature  of  the 
stomach  invading  the  cardia,  employed  osteo-plastic  resection  of  the 
costal  arch,  under  gas  and  ether  anesthesia,  and  thirty  days  later,  under 
spinal  anesthesia,  excised  the  growth,  doing  esophago-gastrostomy. 
Death  occurred  in  eleven  days,  and  was  found  to  be  due  to  a  sub- 
phrenic abscess  occasioned  by  separation  of  the  esophago-gastric 
anastomosis.  Wiener  suggests  doing  a  cervical  esophagostomy  of  the 
lower  end  of  the  esophagus,  and  a  gastrostomy,  instead  of  attempting 
to  unite  the  esophagus  and  stomach.  Lambert's  method  (1914)  of 
exposing  the  cardia,  after  section  of  the  left  coronary  ligament  of  the 
liver,  was  mentioned  at  p.  176  (Figs.  44,  45). 

W.  Meyer  (1915)  collected  15  additional  operations  involving 
resection  of  the  cardia,  including  two  by  himself.  Three  of  thepatients 
recovered  and  were  doing  well  when  reported  several  weeks  after 
operation;  a  few  others  survived  some  days  or  weeks;  but  the  majority 
died  almost  immediately.  Meyer  thinks  an  operation  in  several  stages 
may  ultimately  become  standardized  for  advanced  cases:  (a)  gas- 
trostomy, with  careful  exploration  of  the  cardia;  (b)  excision  of  the 
tumor;  (c)  establishment  of  an  esophageal  fistula  in  the  neck  or  over  the 
upper  sternum.  H.  Brun  (1913),  for  operations  on  the  cardia  prefers 
the  trans-thoracic  route:  he  first  mobilizes  the  duodenum  and  stomach 
and  establishes  a  gastric  fistula  near  the  pylorus;  at  the  second  stage  of 
the  operation  he  opens  the  thorax  and  delivers  the  previously  mobilized 
stomach  through  the  diaphragm,  when  its  excision  becomes  compara- 
tively easy. 

Excision  of  Descending  Duodenum 

Excision  of  Descending  Duodenum.^ — While  it  may  be  impossible  to 
excise  the  head  of  the  pancreas  without  sacrificing  the  duodenum,  on 
account  of  its  blood  supply  (Sauve,  1908;  see  p.  795),  the  reverse  is  not 
the  case,  according  to  Cotte  and  Maurizot  (1910).  These  authors 
point  out  that  the  duodenum  and  pancreas  do  not  present  the  intimate 
anatomical  union  which  classical  anatomy  has  taught.  Their  apparent 
union  is  due  largely  to  the  peritoneal  reflections  developed  during  intra- 
uterine life,  and  these  may  be  separated,  restoring  the  primary  mobility 
of  the  duodenum. 

Resection  of  the  duodenum  may  be  necessary  for  tumors  of  the 


368    TECHNIQUE   OF  OPERATIONS   ON  THE  STOMACH  AND  DUODENUM 

ampulla  of  Vater  (see  p.  591),  or  for  pyloric  tumors  extending  extra- 
ordinarily far  into  the  duodenum;  or  rarely  for  carcinoma  primary  in  the 
duodenum. 

(a)  If  the  duodenum  alone  is  involved,  the  pylorus  being  healthy,  the 
operator  should  begin  by  freeing  the  hepatic  flexure  of  the  colon  by  an 
incision  through  the  parietal  peritoneum  on  its  outer  side,  and  by 
dividing  the  cholecysto-colic  fold.  The  gastrohepatic  omentum  is  then 
opened  above  the  first  part  of  the  duodenum,  and  the  latter  is  depressed. 
The  duodenum  is  then  clamped,  above,  to  the  right  of  the  pyloric 
vessels;  and,  below,  to  the  right  of  the  gastro-epiploica  dextra.  The 
structures  of  the  hepatic  pedicle  (hepatic  artery,  portal  vein,  common 
bile-duct)  are  next  isolated  from  above  downward,  clamping  and 
tying  the  few  arterial  twigs  running  from  the  pancreas  to  the  duodenum. 
If  necessary-  the  main  trunk  of  the  gastro-dubdenal  artery  maj^  be 
ligated,  as  in  Hartmann's  method  of  gastrectomy.  By  now  pulling  on 
the  freed  upper  end  of  the  duodenum,  the  peritoneal  layers  and  fasciae 
which  unite  the  pancreas  to  the  duodenum  are  made  tense:  the  anterior 
layer  is  sectioned  from  above  downward  by  scalpel,  and  then  with 
curved  scissors  the  pancreas  and  duodenum  are  cautiously  separated, 
clamping  and  tying  the  few  vessels  which  remain.  The  posterior 
pancreatico-duodenal  layer  of  fascia  will  be  found  so  attenuated  that  the 
separation  may  easily  be  accomplished  by  the  finger.  Below  the 
region  of  the  ampulla  of  Vater  the  separation  of  the  pancreas  from  the 
duodenum  is  relatively  easy.  Finally  the  duodenum  is  sectioned  just 
to  the  right  of  the  superior  mesenteric  vessels;  the  pancrealico- 
duodenalis  inferior  artery  lies  behind  the  pancreas  and  is  not  apt  to  be 
injured.  After  section  of  the  common  duct  and  the  duct  of  Wirsung, 
the  duodenum  is  entirely  free.  It  remains,  of  course,  to  restore  an 
outlet  for  the  stomach  by  some  form  of  gastro-jejunostomy  and  to 
provide  for  the  implantation  of  the  bile  and  pancreatic  ducts  into  the 
gastro-intestinal  tract.     (For  Kausch's  method,  see  p.  591.) 

{b)  In  resections  of  the  duodenum  for  pyloric  growths,  Hartmann's 
technique  for  partial  gastrectomy  should  be  followed  (p.  353),  sectionijig 
first  the  body  of  the  stomach  and  turning  the  tumor  mass  toward  the 
patient's  right,  approaching  the  pylorus  from  the  rear.  Then  mobilize 
the  descending  duodenum  (p.  784),  and  return  to  the  retropyloric 
region,  opening  by  blunt  dissection  the  layer  of  peritoneum  which  passes 
from  the  pancreas  to  the  posterior  wall  of  the  duodenum.  The  gastro- 
duodenal  and  pyloric  arteries  are  now  tied  and  cut,  whereupon  the 
pylorus,  being  freed  from  all  posterior  attachments,  may  be  drawn  into 
the  wound,  perhaps  far  enough  to  permit  division  of  the  duodenum 


JEJUNOSTOMY  369 

well  beyond  the  tumor.  If  necessary  it  can  be  exposed  to  a  still  lower 
level  by  pulling  on  the  pyloric  mass,  thus  opening  up  the  posterior 
duodeno-pancreatic  angle.  To  go  further  one  must  cut  the  peritoneum 
uniting  the  upper  border  and  anterior  surface  of  the  duodenum  and 
pancreas;  and  as  their  posterior  surfaces  have  already  been  detached, 
the  remainder  is  quite  easy :  all  the  main  arterial  trunks  having  already 
been  tied,  there  is  a  mere  ooze.  The  closure  of  the  stump  of  duodenum 
after  section  becomes  as  simple  as  the  closure  of  any  other  coil  of  small 
intestine. 

Jejunostomy 

Jejunostomy. — -This  operation  was  first  employed  in  1878  by 
Surmay,  of  Ham,  in  the  case  of  a  patient  with  carcinoma;  death  oc- 
curred the  next  day,  from  peritonitis. 


/ 
/' 


Pig.  125. — Jejunostomy  by  the  Method  of  Karewski. 

Karewski  (1896)  adopted  the  method  of  Witzel  for  gastrostomy  (i8gi). 
A  coil  of  the  jejunum  about  45  cm.  from  its  origin  is  selected,  and  the 
catheter  is  sutured  in  place,  as  shown  in  Fig.  125,  with  its  eye  end  toward 
the  anal  end  of  the  bowel.  Then  the  bowel  is  attached  to  the  parietal 
peritoneum  at  the  edges  of  the  abdominal  incision,  and  the  latter  is 
sutured  close  up  to  the  tube.     Feeding  should  be  begun  at  once. 

In  Maydl's  operation  (1898)  the  jejunum  is  completely  divided 
about  20  cm.  below  its  origin,  the  proximal  segment  is  implanted 
(end-to-side  anastomosis)  into  the  distal  about  20  to  30  cm.  below  the 

24 


370    TECHNIQUE   OF   OPERATIONS   ON  THE   STOMACH  ANT)  DUODENUM 

section,  and  the  distal  segment  is  sutured  end-on  into  the  abdominal 
wound  (Fig.  126). 


Fig.  126. — Jejunostomy  in-Y.     Method  of  Maydl. 


Duodenostomy,  in  which  the  iistula  is  made  (after  the  method  of 
Witzel  and  Karewski)  in  the  duodenum  above  the  bile  papilla,  is  pre- 
ferred to  jejunostomy  by  Hartmann  (1903). 


CHAPTER  XV 

COMPLICATIONS  AND  SEQUELS  OF  OPERATIONS  ON  THE 
STOMACH  AND  DUODENUM 

The  operations  which  are  now  employed  in  the  treatment  of  gastric 
diseases  are  much  less  frequently  followed  by  untoward  symptoms 
than  was  the  case  in  the  earlier  periods  of  the  surgery  of  the  stomach. 
Yet  certain  complications  and  sequels  still  demand  attentive  study  by 
the  surgeon,  because  even  now  a  patient  is  occasionally  seen  who  has 
been  operated  on  by  an  antiquated  method,  and  who  presents  the 
symptoms  of  one  of  the  sequels  formerly  not  unusual.  Moreover, 
there  are  certain  complications  and  sequels  which  are  due  to  the 
orginal  disease,  and  not  to  the  operative  treatment:  these  will  always 
deserve  careful  consideration. 

The  main  subjects  to  be  considered  in  this  chapter  are: 

1.  The    Causes   of   Death    after   Operation,    including    Shock, 

Peritonitis,  and  Pneumonia. 

2.  The  Vicious  Circle  after  Gastro-jejunostomy. 

3.  Peptic  Ulcer  of  the  Jejunum  after  Gastro-jejunostomy. 

4.  Internal  Hernia. 

5.  Gastric  Fistulae. 

6.  Duodenal  Fistulse. 

7.  Subphrenic  Abscess. 

I.  The  Causes  of  Death  after  Operation. — The  chief  of  these  are 
Peritonitis,  Pneumonia,  Shock,  and  the  Vicious  Circle.  Unfortu- 
nately most  writers,  while  narrating  their  successes  in  glowing  terms, 
have  not  dwelt  particularly  on  the  details  of  their  fatal  cases,  giving 
only  general  expressions  of  opinion  as  to  the  most  frequent  cause  of 
death. 

In  a  series  of  92  operations  for  benign  diseases  of  the  stomach, 
done  by  the  senior  author  in  the  Lankenau  Hospital,  the  records 
of  which  were  analyzed  by  Whiting,  there  were  8  deaths.  In  two 
patients  (Nos.   i  and  8),  one  operated  on  in  1900,  the  other  in  1903, 

371 


372  COMPLICATIONS    AND    SEQUELS    OF    OPERATIONS 

the  cause  of  death  is  not  noted  in  the  records.  Death  was  at- 
tributed to  exhaustion  in  one  patient  (No.  47),  referred  to  at  page  108, 
who  was  almost  e.xsanguinated  from  repeated  hemorrhages  before  opera- 
tion, but  lived  for  forty-eight  hours  afterward.  Two  patients  (Nos.  7 
and  27),  one  in  1902,  the  other  in  1905,  died  of  peritonitis,  which  was  in 
each  instance  due  to  leakage  of  the  Murphy  button  employed  in  doing 
an  entero-anastomosis  for  vicious  circle  some  days  after  the  primary 
operation  (posterior  gastro-jejunostomy  with  a  long  afferent  loop). 
One  patient  (No.  20),  operated  on  in  1904,  died  from  the  effects  of  the 
vicious  circle  following  the  posterior  "long  loop"  operation,  relief 
not  being  obtained  from  a  secondarj*  operation  in  which  the  distended 
afferent  loop  was  resected  with  end-to-end  anastomosis.  One  patient 
(No.  82)  with  phthisis  died  of  edema  of  the  lungs  developing  on  the 
eighth  day  after  the  operation;  and  one  patient  (No.  67),  with  subacute 
perforation  of  a  gastric  ulcer,  died  three  weeks  after  operation  from 
nephritis  and  myocardial  disease. 

Jn  a  second  series  of  597  operations  for  benign  disease  of  the 
stomach,  there  were  29  deaths  (4.95  per  cent.).  Death  was  attributed 
to  the  following  causes: 

Pneumonia 6 

Peritonitis 5 

Shock 4 

Myocarditis 3 

Acute  cardiac  dilatation ...  2 

Hemorrhage 2 

Obstruction 2 

Toxemia 2 

Asthenia 2 

Pulmonary  edema • i 

29 

The  causes  of  death  recorded  in  other  large  series  of  operations 
for  benign  affections  of  the  stomach  may  be  seen  in  the  accompanying 
tables: 

Beckman  (Mayo  Clinic,  1913):  465  operations,  14  deaths  (3  per 
cent.) . 

Cause  of  death: 

Pulmonary  disease 13 

Tlirombophlebitis i 

14 


CAUSES    OF   DEATH    AFTER    OPERATION  373 

Von  Eiselsberg  (1914):  334  operations,   17   deaths  (5  per  cent.). 
Cause  of  death: 


Hemorrhage  from  ulcer 5 

Anemia  following  hemorrhage 2 

Progressive  ulcer i 

Vicious  circle 2 

Heart  failure  (4  weeks  after  operation) 3 

Peritonitis i 

Pneumonia i 

Paratyphoid  fever i 

Enteritis  and  marasmus i 


17 
Braun  (1914):  75  operations,  8  deaths  (10.6  per  cent.). 


Cause  of  death: 


Hemorrhage  from  ulcer :  .  .  i 

Hemorrhage  from  suture  line 2 

Suture  insufficiency 2 

Pneumonia i 

Vicious  circle i 

Pyschosis i 


It  is,  of  course,  true  that  in  some  of  these  patients  the  operation 
itself  cannot  be  held  directly  responsible  for  the  fatal  termination; 
but  nevertheless  it  is  probable  that  many  of  the  patients  would  not 
have  died  so  soon  if  no  operation  had  been  undertaken. 

In  a  series  of  189  operations  for  carcinoma  of  the  stomach,  b}^  the 
senior  author,  there  were  35  deaths  (18.5  per  cent.): 

Among  81  gastro-jejunostomies  there  were  17  deaths  (21  per 
cent.). 

Cause  of  death: 


Exhaustion 3 

Peritonitis 4  (none  in  the  last  50  operations) 

Shock 2 

Toxemia 2 

Uremia 2 

Cardiac  disease 2 

17 


374 


COMPLICATIONS   AND    SEQUELS    OF    OPERATIONS 


Among  39  partial  gastrectomies,  12  deaths  (10  per  cent.). 
Cause  of  death: 

Exhaustion 2 

Peritonitis 3 

Shock 3 

Pneumonia 2 

Acute  cardiac  dilatation i 

Fecal  fistula i 


One  case  of  total  gastrectomy,  death  from  shock. 
Three  cases  of  transgastric  excisions,  one  death  from  shock. 
Among  39  exploratorj'  operations,  4  deaths  (20  per  cent.). 
Cause  of  death: 


Shock 

Uremia 


The  causes  of  death  recorded  in  other  large  series  of  operations 
for  carcinoma  of  the  stomach  may  be  seen  in  the  accompanying  tables: 

Altschul  (1913):  Anterior  Gastro-jejunostomy,  88  operations,  31 
deaths  (35.2  %). 

Cause  of  death: 

Peritonitis 9  (5  from  perforation  of  bjtton  used  in 


anastomosis,    i    from   suture  insuffi- 
ciency, 3  from  operative  technique) 


Pneumonia 

Vicious  circle 

Obstruction  of  bowel. 

Marasmus 

Anemia 

Cardiac  disease. . . 

Phthisis 

No  autopsy 


Posterior  Gastro-jejunostomy,  95   operations,  18  deaths   (18  per 


cent.). 

Cause  of  death: 


Peritonitis 

Pneumonia 

Pulmonary  embolism. . 

Cardiac  disease 

Cachexia 

Hemorrhage  from  tumor 

Vicious  circle 

Gangrene  of  colon 


18 


CAUSES    OF    DEATH   AFTER    OPERATION  375 

Partial  Gastrectomy,  64  operations,  26  deaths  (40.6  per  cent.). 
Cause  of  death: 

Peritonitis 7 

Pneumonia 9 

Cachexia 4 

Cardiac  disease 2 

Pleuritis i 

Gastric  atony i 

Intercurrent  dysentery .  i 

No  autopsy ...  i 

26 

Jejunostomy,  5  operations,  4  deaths  (80  per  cent.). 
Cause  of  death: 

Peritonitis 2 

Pneumonia ....  2 


Exploratory  Laparotomy,  139  operations,  15  deaths,  (10.8  per  cent). 
Cause  of  death: 


Peritonitis 

...        2 

(one  from  perforation  by  the  cancer' 

Pneumonia 

.  .             6 

Pulmonary  embolism. 

Cerebral  embolism 

Marasmus 

Cardiac  disease 

Gangrene  of  colon 

Xo  autopsy i 


One  case  of  total  gastrectomy,  death  in  2  days. 

Weil  (1913),  13s  partial  gastrectomies,  31  deaths  (23  per  cent.). 

Cause  of  death: 

Peritonitis 18 

Pulmonary  disease 8 

Shock 2 

Cachexia i 

Cerebral  embolism i 

.Acute  enteritis i 

31 

The  subject  of  the  Vicious  Circle  after  gastro-Jejunostomy  deserves 
a  section  to'itself.     It  will  be  sufficient  here  to  refer  rather  briefly  to 


376  COMPLICATIONS   AND    SEQUELS    OF   OPERATIONS 

the  subjects  of  shock,  pneumonia,  and  peritonitis,  comphcating  and 
following  operations  on  the  stomach. 

Shock  is  chiefly  due  to  undue  prolongation  of  the  operation  on  the 
surgeon's  part,  or  to  pre-existing  cachexia  on  that  of  the  patient.  It  is 
the  surgeon's  duty,  so  far  as  in  him  lies,  to  select  that  form  of  operation 
the  unavoidable  shock  of  which  that  patient  will  be  able  to  withstand. 
Ability  so  to  select  this  operation  conies  to  the  surgeon  as  the  result 
of  experience,  and  is  with  difficulty  learned  from  a  text-book.  It 
should,  however,  be  the  surgeon's  desire  always  to  aim  in  the  direction 
of  safety,  remembering  that  excellent  motto  "primum  non  nocere." 
In  the  case  of  very  weak  patients  even  an  exploration  may  seem  con- 
tra-indicated; in  others,  gastrostomy,  jejunostomy,  or  even  gastro- 
enterostomy can  be  performed,  and  a  radical  operation,  when  indicated, 
may  be  postponed  until  some  strength  shall  have  been  gained  by  forced 
feeding. 

When  the  operation  has  once  been  undertaken,  the  actual  technique 
of  its  performance  will  influence  very  materially  the  development  of 
shock.  We  always  lay  great  stress  on  maintaining  the  natural  heat  of 
the  body.  To  this  end  the  patient  should  wear  a  jacket  of  cotton 
wadding,  and  his  lower  extremities  should  be  similarly  clothed. 
In  addition  to  these  precautions  a  hot-water  bed  which  covers  the  entire 
top  of  the  operating  table  may  be  used.  We  believe  the  use  of  an 
electrically  heated  mattress  is  dangerous:  it  is  too  easily  overheated. 
These  measures  joined  to  the  tonic  treatment  to  which  the  patient 
has  been  submitted  during  the  day  or  so  immediately  preceding  the 
expected  operation,  will  in  the  vast  majority  of  cases  prevent  the  oc- 
currence of  shock.  Indeed,  recently  we  have  observed  that  patients 
recover  as  bhthely  from  even  extensive  gastrectomies  as  they  do  from 
an  "interval"  operation  for  appendicitis.  When  the  bodily  heat  is 
thus  maintained,  and  when  the  surgeon  eventrates  no  viscera  except 
those  immediately  concerned  in  the  operative  procedure,  the  actual 
duration  of  the  operation  seems  to  have  little  tendency  to  produce 
shock,  at  least  in  the  case  of  chronic  lesions.  Five  minutes  more 
consumed  in  an  operation  will  very  rarely  be  prejudicial  to  the  patient, 
and  will  certainly  enable  the  surgeon  to  do  the  operation  more  thor- 
oughly, and  therefore  with  more  prospect  of  ultimate  success,  than  if  he 
is  continually  trying  to  establish  a  record.  We  regard  thirty  minutes 
as  a  short  time  to  spend  in  doing  a  gastro-jejunostomy,  and  are  not  at 
all  ashamed  of  taking  more  than  twice  as  long  in  difl&cult  cases  of  gastric 
surgery. 

Hemorrhage  predisposes  to  shock.     The  surgeon,  however,  who 


PNEUMONIA  377 

pursues  a  definite  plan  in  his  gastric  operations,  and  has  the  necessary 
acquaintance  with  the  anatomy  of  the  parts,  is  not  apt  to  encounter 
uncontrollable  hemorrhage.  Indeed,  in  all  typical  operations  there 
should  be  no  bleeding,  as  every  blood-vessel  is  clamped  or  tied  before 
it  is  divided.  Yet  where  the  adhesions  are  very  dense,  and  where  the 
anatomical  landmarks  are  with  difficulty  distinguishable,  rather 
profuse  hemorrhage  may  be  encountered.  The  senior  author  has  been 
forced  to  abandon  a  gastrectomy  for  cancer,  and  resort  to  gastro- 
jejunostomy, on  account  of  furious  hemorrhage  among  pyloric 
adhesions. 

Pneumonia. — Among  the  authors'  patients  there  have  been  very 
few  deaths  from  pneumonia:  8  deaths  in  nearly  800  operations  on 
the  stomach.  Beckman  (1913),  from  the  Mayo  clinic,  reported  13 
deaths  from  pulmonary  disease  among  465  operations  all  for  benign 
disease;  Altschul  (1913)  31  deaths  from  pneumonia  among  391  opera- 
tions, all  for  malignant  disease.  We  attribute  the  absence  of  pneu- 
monia as  a  postoperative  complication  in  our  own  experience  largely 
to  the  precautions,  already  mentioned,  which  are  taken  against  chilHng 
the  patients;  but  chiefly  to  the  semi-sitting  posture  assumed  as  soon 
as  the  effects  of  the  anesthetic  pass  off,  and  particularly  to  the  use  of 
nitrous  oxide  and  oxygen  anesthesia  in  very  debilitated  patients. 

It  is  well  known  that  pneumonia  is  more  liable  to  follow  operations 
in  the  region  of  the  upper  abdomen  than  those  in  the  pelvis;  and  this 
predisposition  has  been  attributed  to  various  causes.  The  anesthetic 
could  have  no  more  harmful  influence  in  one  case  than  in  the  other; 
indeed,  according  to  Krecke,  as  long  ago  as  1901  v.  MikuHcz  reported 
a  much  higher  mortahty  from  pneumonia  after  gastric  operations  under 
local  anesthesia  than  when  a  general  anesthetic  was  employed.  How- 
ever, it  is  certainly  well  for  the  anesthetist  to  bear  in  mind  that  the 
visceral  peritoneum  is  insensitive  (Lennander) ,  and  that  when  once  the 
abdomen  has  been  opened,  comparatively  light  anesthsia  is  required 
until  the  time  comes  for  closing  the  incision  in  the  abdominal  wall. 

We  are  inclined  to  agree  withKelhng  (1905)  who  held  that  post-opera- 
tive pneumonia  in  these  cases  is  produced  either  by  inhalation  or  by 
direct  infection  through  the  diaphragm;  its  much  greater  frequency  in 
malignant  and  infectious  conditions,  than  in  cases  of  simple  pyloric 
stenosis  or  gastric  dilatation  is  well  recognized.  Others  have  taught 
that  the  incision  in  the  epigastric  region  of  the  abdomen  interferes  with 
deep  breathing  after  the  operation,  and,  the  patient  restricting  his 
respiratory  excursions  as  far  as  possible  on  account  of  pain,  in  this  way 
the  smaller  bronchial  tubes  become  clogged  with  mucus,  hypostatic 


378  COMPLICATIONS   AND   SEQUELS    OF    OPERATIONS 

congestion  is  induced,  and  the  onset  of  pneumonia  favored.  To 
prevent  respiratory  difficulty  during  the  operation,  we  have  the  pa- 
tient's arms  laid  beside  him  on  the  table,  never  pinned  up  over  his 
chest.  The  elaborate  study  of  Cutler  and  Hunt  (1920)  on  post-opera- 
tive pulmonary  complications  leads  them  to  adopt  the  view  that  they 
are  with  very  few  exceptions  of  embolic  origin;  embolism  which  may 
occur  through  the  lymphatics  or  the  blood  stream,  is  favored,  as  they 
point  out,  by  sepsis,  by  trauma,  and  by  the  mobility  of  the  part,  factors 
which  arc  all  present  in  many  operations  on  the  upper  abdominal 
viscera. 

Since  surgeons  have  adopted  the  habit  of  sitting  their  patients  up 
in  bed  soon  after  the  operation,  the  prevalence  of  post-operative 
pneumonia  in  gastric  cases  has  markedly  diminished;  and  thus  this 
practice,  begun  with  the  erroneous  idea  that  the  stomach  was  emptied 
by  gravity,  has  been  productive  of  good  results,  in  spite  of  its  mistaken 
purpose. 

As  urged  by  Robson,  it  is  well  to  direct  these  patients  to  inhale 
deeply  three  or  four  times  every  hour  or  so,  in  the  hope  that  thus 
pneumonia  will  be  prevented,  by  ridding  the  terminal  bronchioles  of 
accumulated  secretion. 

It  has  long  been  our  belief  that  the  injudicious  use  of  saline  solu- 
tion intravenously,  as  a  remedy  or  supposed  preventative  of  shock, 
had  a  tendency  to  predispose  to  pulmonary  complications,  and 
especially  to  edema  of  the  lungs.  Its  value  in  hemorrhage  may  perhaps 
be  allowed;  but  when  care  is  taken  to  prevent  the  dissipation  of  bodily 
heat  it  is  very  exceptional  indeed  in  our  experience  for  patients  to  be 
so  shocked  during  any  operation,  unattended  by  hemorrhage,  as  to 
require  the  use  of  sahne  solution  intravenously. 

Should  pneumonia  unfortunately  develop,  no  time  should  be  lost 
in  applying  dry  cups  to  the  patient's  chest,  and  adopting  vigorous 
medical  treatment  and  putting  the  patients  in  the  open  air. 

Peritonitis. — Among  the  senior  author's  patients  up  to  1909  there  had 
been  2  deaths  from  peritonitis  in  the  benign  series.  In  these  patients 
the  primary  operation  had  been  a  posterior  gastro-jejunostomy  with 
long  loop  (the  first  operation  in  1902,  the  second  in  1905);  in  both  a 
secondary  entero-anastomosis  was  done  on  account  of  the  development 
of  the  circulus  vitiosus;  and  in  both  leakage  occurred  after  the  second 
operation,  in  which  the  Murphy  button  was  employed,  and  death 
followed  some  days  later  from  peritonitis.  This  form  of  operation 
(long  loop)  has  not  been  employed  since  September,  1905,  and  the 
use  of  the  Murphy  button  is  avoided  whenever  possible.     Since  1909, 


PERITONITIS  379 

there  have  been  5  deaths  from  peritonitis  among  597  operations  of  all 
kinds  for  benign  disease;  and  among  a  total  of  189  operations  for 
malignant  disease  there  have  been  7  deaths  from  peritonitis. 

Simplification  of  technique,  and  more  especially  the  popularization 
of  rubber-covered  clamps  in  abdominal  surgery,  has  nearly  eliminated 
peritonitis  as  a  post-operative  cause  of  death  in  benign  diseases  of 
the  stomach.  Occasionally,  to  be  sure,  a  death  after  operation  is  en- 
countered from  the  subsequent  perforation  of  a  gastric  or  duodenal 
ulcer;  but  these  are  very  rare  cases,  as  are  also  the  cases  in  which  peptic 
ulcer  of  the  jejunum  develops  and  perforates  before  convalescence  is 
established. 

But  it  cannot  be  denied  that  peritonitis  is  much  more  to  be  feared 
in  maUgnant  than  in  non-malignant  disease,  and  there  probably  always 
will  be  a  small  proportion  of  deaths  due  to  unavoidable  peritonitis. 
In  the  last  50  gastro-jejunostomies  for  carcinoma  (up  to  1920). there 
had  been  no  deaths  from  peritonitis,  but  there  were  4  deaths  among  the 
preceding  31  operations  of  gastro-jejunostomy.  In  the  first  of  these 
cases  (Feb.  3,  1905),  the  operation  was  a  posterior  gastro-jejunostomy 
with  long  loop,  with  primary  entero-anastomosis  by  a  Murphy  button; 
the  patient  died  on  the  sixth  day,  and  at  autopsy  an  abscess  was  found 
between  the  loops  of  small  intestine  concerned  in  the  entero-anastomosis, 
thus  making  the  third  fatal  case  to  be  attributed  to  the  use  of  the  Mur- 
phy button.  In  the  second  case  (Dec.  14,  1905),  posterior  short  loop 
gastro-jejunostomy  was  done,  and  the  patient  died  on  the  eleventh 
day  from  perforation  of  a  jejunal  ulcer  on  the  proximal  side  of  the  gastro- 
enterostomy. In  the  third  case  (March  12,  1906)  the  fatal  result  is  to 
be  attributed  to  the  diseased  condition  of  the  gastric  wall  at  the  site 
of  the  anastomosis.  This  we  think  is  the  element  that  can  never 
wholly  be  eliminated  as  a  cause  of  peritonitis  in  these  cases.  In  the 
patients  treated  by  partial  gastrectomy  it  usually  will  be  possible  to 
cut  so  wide  of  the  diseased  area  that  the  sutures  will  hold  securely; 
but  where  only  a  palliative  operation  is  attempted,  the  surgeon,  rather 
than  do  nothing,  or  rather  than  do  a  jejunostomy,  will  often  be 
tempted  to  make  an  anastomosis  in  a  portion  of  the  stomach  wall 
already  affected,  and  thus  run  the  risk  of  peritonitis  developing.  The 
fourth  and  last  of  the  carcinoma  patients  to  die  from  peritonitis  after  a 
palliative  operation  (April  13,  1907)  had  a  malignant  growth  involving 
the  pylorus,  the  gastro-hepatic  omentum,  the  transverse  mesocolon, 
and  the  pancreas,  causing,  in  addition  to  the  pyloric  obstruction,  a 
stenosis  of  the  transverse  colon  and  dilatation  of  the  gall  bladder. 
The  operations  done  were:  posterior  gastro-jejunostomy,  with  short 


380  COMPLICATIONS   AND    SEQUELS    OF   OPERATIONS 

loop;  cholecysto-colostomy;  and  entero-colostomy.     Death  occurred 
on  the  fourth  day  from  fibrino-purulent  peritonitis. 

Three  patients  died  from  peritonitis  after  partial  gastrectomy  for 
carcinoma  (among  46  such  operations) .  In  two  no  leakage  of  the  sutured 
areas  could  be  detected  after  death;  in  the  third  this  was  the  cause  of 
the  peritonitis. 

n.  The  Vicious  Circle  after  Gastro-jejunostomy. — By  the  Circulus 
.  Vitiosus  was  formerly  understood  a  train  of  post-operative  sjTiiptoms 
believed  to  be  due  to  the  continued  escape  of  gastric  contents  by  way 
of  the  pylorus,  and  the  return  of  the  duodenal  contents  into  the  stomach 
through  the  afferent  loop  by  way  of  the  gastro-intestinal  anastomosis. 
Fowler  (1902)  suggested  the  term  reflux  to  indicate  that  condition  where 
the  duodenal  secretions  (afferent  loop)  or  those  of  the  jejunum  (efferent 
loop)  passed  into  the  stomach  through  the  gastro-intestinal  anastomosis 
arid  produced  vomiting,  but  where,  for  one  cause  or  another,  the  gastric 
contents  did  not  obtain  access  to  the  afferent  loop  through  the  pylorus. 
Surgeons  have  thus  spoken  of  the  duodenal  and  the  jejunal  reflux,  or 
have  designated  the  latter  condition  as  intestinal  regurgitation.  In 
general,  however,  the  expression  vicious  circle  has  been  indiscriminately 
appHed  to  pernicious  or  persistent  vomiting  after  gastro-jejimostomy; 
and  as  our  knowledge  of  the  normal  physiology  of  the  stomach  has 
increased,  and  as  our  ideas  of  the  mechanism  of  the  operation  of  gastro- 
jejunostomy have  been  very  materially  altered  within  recent  years,  it 
is  scarcely  desirable,  even  were  it  possible,  to  make  a  distinction  in  the 
cause,  where  we  can  perceive  no  difference  in  the  result.  Indeed,  it  is 
extremely  probable  that  in  most  cases  of  gastro-jejunostomy  by  lateral 
anastomosis,  with  open  pylorus,  precisely  the  course  of  events  occurs 
which  is  stated  above  to  have  been  the  supposed  cause  of  the  vicious 
circle. 

A  discussion  of  the  supposed  causes  of  this  condition  is,  however, 
of  historical  interest.  No  less  a  surgeon  than  Terrier  has  tersely  said 
that  it  is  due  to  faulty  operating — in  other  words,  that  it  is  avoidable 
by  proper  technique.  Certain  it  is,  that  with  increased  experience 
the  surgeon  encounters  it  less  often,  and  that  long  series  of  operations 
have  been  reported  by  various  surgeons,  without  having  it  once  occur. 
With  the  modern  operation  of  gastro-jejunostomy  it  is  rarely  if  ever 
seen;  and  although  most  surgeons  have  abandoned  the  anterior  opera- 
tion (save  in  certain  cases  of  carcinoma)  as  well  as  posterior  operations 
with  a  long  afferent  loop,  because  they  believe  these  more  apt  to  be 
followed  by  the  \'icious  circle  than  the  "  no  loop"  method  originated  by 
Petersen  and  popularized  among  surgeons  of  Great  Britain  and  America 


VICIOUS   CIRCLE 


381 


by  Moynihan,  yet  there  are  still  a  few  surgeons,  including  Paterson 
of  London,  who  persist  in  employing  anterior  gastro-jejunostomy  and 
who  obtain  entirely  satisfactory  results. 

Ever  since  the  operation  of  gastro-jejunostomy  was  first  done, 
without  premediatation,  by  Wolfler,  in  188 1,  surgeons  have  been  seeking 
some  method  by  which  this  vicious  circle  could  be  avoided.  It  is 
needless  here  to  describe  all  the  technical  changes  which  the  operation 
has  undergone  in  attempting  to 
eliminate  this  complication.  Each 
individual  method  has  been  adopted 
to  overcome  what  the  surgeon  be- 
lieved was  the  cause  of  the  vomit- 
ing. Those  who  thought  it  was  due 
to  spur  formation  at  the  site  of 
the  gastro-jejunostomy  wound, 
aimed  to  prevent  this  by  attaching 
the  jejunum  to  the  stomach  for 
some  distance  both  above  and  below 
the  opening  (Hadra,  1891;  Lauen- 
stein,  1896);  those  who  thought  it 
was  due  to  contraction  of  the  anasto- 
motic opening  took  measures  to  in- 
sure its  patency  (excision  of  mucosa, 
Littlewood;  Moynihan);  those  who 
thought  it  was  produced  by  pyloric 
regurgitation,  obliterated  the  pylo- 
rus  (Mayo,   1903);  and  those  who 

thought  that  it  depended  on  the  discharge  of  the  contents  of  the  afferent 
loop  into  the  stomach,  or  on  obstruction  to  the  discharge  from  the  affer- 
ent into  the  efferent  loop,  took  measures  to  overcome  this  difficulty — 
some  doing  an  entero-anastomosis  between  the  afferent  loops  (Lauen- 
stein,  1890;  Braun;  Jaboulay),  and  others  still  further  compHcating  the 
operation  by  constricting  (Wolfler;  Chaput;  v.  Hacker;  Fowler)  or 
actually  dividing  (Doyen)  the  afferent  loop  between  the  entero-anasto- 
mosis and  the  gastro-jejunostomy.  But  the  fact  remained  that  no 
one  surgeon  was  able  to  assign  a  satisfactory  cause  for  the  condition, 
nor  always  able  to  avoid  it  however  great  his  experience  may  have 
been  with  the  operation,  or  with  this  much  dreaded  sequel.  The 
theories  of  Chluniskij  (spur  formation),  of  Steudel  (contraction  of 
the  opening  in  the  transverse  mesocolon)  and  of  Kelling,  have  all  been 
disproved  in  some  instances;  and  although  we  are  forced  to  the  rather 


Fig.  127. — Diagram  to  Show  Course  of 
Gastric  and  Duodenal  Contents.  Black 
Arrows  Indicate  Normal  Course,  Red 
Arrows  Indicate  Course  after  Anterior 
Gastro-jejunostomy  with  Entero-anasto- 
mosis. 


382  COMPLICATIONS    AND    SEQUELS    OF    OPERATIONS 

humiliating  conclusion  that  we  do  not  know  definitely  what  the  actual 
cause  is,  we  are  at  any  rate  convinced  that  it  is  best  avoided  by  adopting 
a  simplified  instead  of  a  complicated  technique,  and  by  giving  occasion 
for  the  production  of  as  few  post-operative  adhesions  as  possible. 

The  theories  suggested  to  explain  the  vicious  circle  may  be  classed 
under  the  following  heads: 

1.  The  presence  of  bile  orpancreatic  juice  in  the  stomach.  Although 
excessive  amounts  of  these  mny  cause  nausea,  acid  eructations,  and 
even  annoying  vomiting,  they  cannot  alone  be  held  sufl5cient  to  account 
for  severe  cases  of  the  vicious  circle.  Dastre's  experiments  on  dogs, 
and  operations  of  cholecyto-gastrostomy  by  Terrier  and  others,  show 
that  bile  is  well  tolerated  by  the  stomach;  while  the  success  of  Moyni- 
han's  well-known  case,  in  which,  for  rupture  of  the  intestine  at  the 
duodeno-jejunal  juncture,  the  proximal  end  of  the  bowel  was  closed  and 
the  distal  united  with  the  stomach  (see  p.  308),  thus  forcing  all  the  duo- 
denal contents  to  traverse  the  stomach  before  reaching  the  jejunum, 
effectually  sets  aside  the  theory  that  pancreatic  juice  in  the  stomach  is 
solely  responsible  for  the  s}Tnptoms.  Indeed,  as  already  remarked, 
it  is  extremely  probable,  if  not  absolutely  certain,  in  most  of  the  gastro- 
jejunostomies done  by  lateral  anastomosis  at  the  present  day,  that  the 
secretions  of  the  afferent  loop  mix  freely  in  the  stomach  with  the  gastric 
contents,  and  really  are  of  benefit  to  the  patient  (p.  in). 

2.  The  location  of  the  anastomotic  orifice  at  some  other  than  the 
"most  dependent  portion"  of  the  stomach.  This  is  assuredly  not 
a  cause,  in  itself,  since  we  now  know,  and  might  have  known  twenty 
years  ago,  if  we  had  heeded  the  researches  of  KeUing,  that  the  stomach 
empties  itself  only  by  contraction,  not  by  gravity.  Moreover,  many 
successful  operations  have  been  done  without  regard  to  the  location 
of  the  anastomosis  at  the  "most  dependent  point."  Indeed,  that  point 
where  the  anastomosis  is  made  may  soon  become  the  ''most  dependent 
point"  by  the  drag  of  the  intestine;  and  yet  what  is  the  most  depen- 
dent point  when  the  patient  is  erect,  will  not  be  so  when  he  is  in  bed. 
All  of  which  shows  the  folly  which  inspired  surgeons  who  regarded 
the  stomach  as  a  tin  can  which  to  be  drained  must  have  a  hole  cut  in  its 
bottom,  and  must  then  be  kept  on  end  if  it  were  to  be  kept  empty. 

3.  The  presence  of  a  long  afferent  loop  has  been  blamed,  but, 
as  already  mentioned,  many  entirely  successful  operations  disprove 
this  theory,  and  we  must  look  elsewhere  for  a  cause. 

4.  Obstruction  at  the  gastro-jejimal  anastomosis,  of  some  form  or 
other,  is,  we  believe,  the  true  cause  of  this  condition.  The  vicious 
circle  was  more  frequent  in  the  earlier  operations  because  the  surgeon 


VICIOUS   CIRCLE  383 

damaged  the  bowels  and  the  stomach  more,  and  produced  temporary 
paresis,  or  more  lasting  adhesions;  or  because  the  operation  was  followed 
by  the  formation  of  a  spur,  a  kink,  a  valve  of  mucous  membrane, 
or  some  other  form  of  mechanical  obstruction.  Kelling  very  clearly 
pointed  out  that  if  the  stomach  was  damaged  (either  by  the  operation 
01  by  previous  disease,  as  in  far  advanced  cancer  cases),  it  could  not 
properly  contract  after  the  gastro-jejunostomy ;  and  that  under  such 
circumstances  the  intestines  would  empty  themselves  into  it.  He 
insisted,  moreover,  on  the  gastro-duodenal  reflex,  by  virtue  of  which 
the  gastric  contractions  cease  so  long  as  the  duodenum  remains  full. 
If,  therefore,  there  was  a  patulous  pylorus,  or  if  with  obstructed 
pylorus  the  gastric  contents  by  reverse  peristalsis  gained  access  to  the 
duodenum  (the  afferent  loop),  the  stomach  could  no  longer  empty 
itself  by  peristalsis  until  the  duodenum  was  emptied;  and  if  this  was 
prevented  by  an  obstruction  at  the  site  of  the  anastomosis,  circum- 
stances were  very  favorable  for  the  the  development  of  the  vicious 
circle.  We  will  recur  again  to  this  topic  when  discussing  the  symp- 
toms of  the  vicious  circle. 

The  employment,  then,  of  a  suitable  technique  will  prevent  ob- 
struction to  the  afferent  loop  at  the  gastro-jejunal  anastomosis,  and 
will  prove  the  correctness  of  Terrier's  contention  that  the  vicious  circle 
is  due  to  faulty  operating. 

The  symptoms  of  the  vicious  circle  usually  do  not  develop  for 
several  days  after  the  operation.  At  first  there  may  be  merely  a  slight 
regurgitation  of  bile-stained  fluid;  later,  when  more  food  is  taken, 
upper  jejunal  contents  may  be  vomited,  the  regurgitation  then  taking 
place  from  the  efferent  loop. 

Several  cases  have  come  under  our  observation  in  which  conval- 
escence after  the  gastro-jejunostomy  was  satisfactory,  but  occasionally 
there  would  be  copious  vomiting  of  biliary  matter.  Meals  were  eaten 
with  appetite,  no  discomfort  ensued,  but  three  or  four  hours  after  the 
meal  this  copious  biliary  vomiting  would  occur.  The  patients  did 
not  lose  in  weight.  One  patient  gained  forty  pounds  during  the  first 
year  after  the  gastro-jejunostomy,  but  the  vomiting  of  pancreatic  and 
bilious  fluids  was  so  persistent  and  annoying  that  she  finally  sub- 
mitted to  another  operation. 

There  were  sometimes  seen  instances  of  the  vicious  circle  which 
more  imperatively  demanded  relief  than  those  patients  just  mentioned. 
In  such  cases  the  vomiting  was  persistent  from  the  time  of  the  opera- 
tion, emaciation  was  rapid,  and  unless  something  had  been  done 
speedily  to  relieve  the  patients,  they  would  have  died  of  exhaustion 


384  COMPLICATIONS  AND    SEQUELS   OF   OPERATIONS 

and  inanition;  in  fact,  all  the  symptoms  of  a  high  intestinal  obstruc- 
tion were  present. 

The  treatment  should  at  first  be  palliative.  The  patient  should 
be  sat  up  in  bed,  the  stomach  washed  out,  and  all  food  by  the  mouth 
stopped.  Enteroclysis  should  be  employed  if  mouth  feeding  cannot 
be  resumed  promptly.  When  vomiting  has  been  absent  for  twenty- 
four  or  thirty-six  hours,  a  very  little  water  may  be  given  by  mouth — a 
teaspoonful  every  hour  or  two;  but  this  must  again  be  stopped  if  the 
vomiting  reappears.  In  the  less  severe  cases  it  is  sometimes  sufficient 
to  employ  lavage  every  second  or  third  day;  light  diet,  in  small  quanti- 
ties, being  taken  meantime.  We  have  known  a  patient  content  to 
live  in  this  way  for  some  months. 

If  a  cure  is  not  spontaneously  effected  thus,  or  immediately  if  the 
symptoms  are  urgent,  the  abdomen  should  be  reopened,  and  mechan- 
ical correction  of  the  obstruction  attempted.  Operation  should  not 
be  postponed  so  long  that  the  patient's  strength  will  not  be  sufficient 
to  stand  the  shock;  and,  on  the  other  hand,  too  extensive  an  operation 
should  not  be  employed  on  such  debilitated  patients. 

The  following  case,  which  has  been  published  elsewhere  in  detail 
by  the  senior  author,  is  quoted  here  as  illustrating  many  points  of 
importance  in  this  connection. 

A  young  woman  of  24  years,  who  for  three  years  had  presented  symptoms  of  gradually 
increasing  pyloric  obstruction,  was  operated  on  at  the  German  Hospital,  by  Dr.  John  B. 
Deaver,  July  8,  1903.  Numerous  adhesions  were  found  about  the  neck  of  the  gall-bladder 
and  duodenum.  The  gall-bladder  was  normal,  but  slightly  distended;  the  stomach  was 
slightly  enlarged,  somewhat  proptosed,  and  the  pylorus  was  thickened.  A  posterior 
trans-mesocolic  gastro-jejunostomy  was  done,  n-ith  sutures,  the  afferent  loop  being  about 
25  cm.  (ten  inches)  long. 

The  patient  did  well  and  was  free  from  vomiting  for  five  days.  On  July  13th,  700  cc.  of 
dark  green  bile  were  vomited;  her  general  condition  was  good. 

July  15th.  Patient  vomited  bUe  during  the  night.  Appetite  good,  feels  better  than 
she  has  in  years.     Stitches  removed.     Wound  healed. 

July  17th.     Patient  vomited  bile  with  small  portion  of  fecal  matter. 

July  i8th.  During  early  morning  the  patient  vomited;  vomitus  stercoraceous  in 
character,  about  300  cc;  and  an  intestinal  obstruction  was  believed  to  have  taken  place 
necessitating  a  second  operation. 

Second  operation,  July  18,  1903  (ten  days  after  the  lirst  operation).  Omentum  found 
adherent  to  abdominal  scar;  adhesions  separated,  and  omentum  and  transverse  colon  were 
turned  upward.  This  reflection  upward  carried  several  coils  of  small  bowel  along,  and  it 
was  found  that  the  proximal  and  distal  limbs  of  the  anastomosed  loop  were  firmly  adherent 
to  the  posterior  layer  of  the  transverse  mesocolon,  interfering  to  a  marked  degree  with  the 
peristalsis  of  the  bowel.  The  adhesions  were  all  separated,  and  the  denuded  surfaces  were 
inverted  with  silk  sutures,  or  covered  with  Cargile  membrane.  The  gastro-jejunostomy 
was  apparently  perfect.  An  entero-enterostomy  was  then  performed,  by  sutures,  15  cm, 
(six  inches)  from  the  gastric  anastomosis.     (See  Fig.  127.) 


VICIOUS    CIRCLE  385 

There  was  some  vomiting  of  green  material  upon  the  two  days  following  operation 
but  this  stopped  upon  the  use  of  lavage. 

July  25th.     Stitches  removed,  wound  healed. 

July  26th.  Patient  vomited  twice  about  300  cc.  of  light  greenish  material.  Wine  of 
ipecac,  10  drops  every  hour,  was  given. 

July  27th.     No  vomiting. 

July  31st.     Ipecac  stopped. 

Aug.  2nd.  Vomited  300  cc.  of  light  green  material  about  10  p.  m.  Vomiting  could  not 
be  attributed  to  anything  eaten.  Given  10  drops  of  wine  of  ipecac  every  two  hours  during 
day. 

Aug.  7th.     Vomited  small  quantity  of  yellow  material.     Ipecac  stopped. 

Aug.  I2th.  Discharged.  Condition  fine;  is  gaining  weight,  and  has  not  vomited  since 
Aug.  7th. 

On  Sept.  14,  1903,  this  patient  was  readmitted  to  the  German  Hospital.  She  stated 
that  on  Aug.  i6th,  four  days  after  her  discharge,  vomiting  had  recommenced,  at  first  of  bile 
and  later  of  food  and  bile.  When  admitted  she  vomited  everything  given  by  mouth,  and 
large  quantities  of  thick,  ropy,  dark  green  material,  with  a  very  strong  odor.  Feeding  by 
rectum  was  begun,  but  the  patient  continued  to  vomit  the  thick,  dark  green  material, 
containing  large  quantities  of  bile.  On  washing  out  the  stomach  large  quantities  of  the 
same  material  were  obtained.  She  was  well  nourished,  notwithstanding  the  vomiting, 
proving  that  the  food  must  have  been  digested  in  great  part,  especially  as  the  patient  did 
not  seem  to  have  lost  much  weight.  Examination  of  the  eyes  was  negative;  the  pehic 
organs  were  normal;  and  no  constitutional  cause  for  the  vomiting  could  be  found. 

Third  Operation,  Sept.  19,  1903.  The  omentum  was  found  universally  adherent,  and 
there  were  dense  adhesions  between  the  coils  of  bowel.  The  gastro-jejunostomy  was 
exposed,  and  the  opening  found  to  be  freely  patent.  The  entero-enterostomy  was  exposed, 
some  difficulty  being  encountered  in  distinguishing  the  anastomosis  by  reason  of  the 
numerous  adhesions.  When  these  were  seperated  the  anastomosis  was  found  to  be  in 
perfect  condition,  with  some  sacculation.  Adhesions  were  further  separated  throughout  the 
abdominal  cavity.  The  entire  omentum  was  ligated  and  cut  away.  The  gall-bladder  was 
found  normal  in  size,  numerous  adhesions  surrounding  it;  the  stomach  was  normal  in  size. 
By  means  of  a  pedicle  needle  a  piece  of  silver  mre  was  passed  around  the  pylorus  and  tied. 
The  abdominal  cavity  was  filled  with  normal  salt  solution,  and  the  abdominal  wound  closed 
by  tier  suture.  The  patient  was  shocked,  the  pulse  being  barely  perceptible  at  the  close 
of  the  operation.  An  intravenous  injection  of  saline  solution  was  given  before  she  left  the 
operating  room. 

Sept.  20.     Patient  vomited  bile  several  times  during  the  day. 

Sept.  22.  Buttermilk  ordered.  Patient  feels  somewhat  distressed  in  the  epigastric 
region,  no  vomiting. 

Sept.  23.     Patient  feels  well;  no  epigastric  distress. 

Sept.  29.  Eating  light  diet.     No  nausea  or  distress. 

Oct.  10.     Patient  vomited  after  breakfast. 

Oct.  11-15.  Patient  vomited  several  times  each  day;  complained  of  some  abdominal 
pain;  there  was  some  tympanites.  For  symptoms  of  obstruction,  it  was  determined  the 
next  day  to  re-open  the  abdomen. 

Fourth  Operation,  Oct.  16,  1903.  .\  coil  of  small  intestine  was  found  closely  adherent 
to  the  parietal  peritoneum.  The  intestines  were  found  universally  adherent  to  each 
other,  and  to  the  remains  of  the  omentum,  binding  together  the  transverse,  ascending 
and  descending  colon  and  sigmoid  flexure,  and  various  loops  of  small  intestine,  one  to 
another.  No  portion  of  the  bowel,  excepting  about  five  feet  of  the  ileum,  was  free  from 
adhesions.  The  adhesions  were  separated,  bleeding  points  ligated,  and  all  denuded  sur- 
faces covered  with  Cargile  membrane.  The  entero-enterostomy  and  the  gastro-jejunos- 
tomy were  examined  and  found  patulous.  At  no  portion  were  the  intestines  collapsed  or 
25 


386  COMPLICATIONS    AND    SEQUELS    OF    OPERATIONS 

unduly  distended.  The  abdomen  was  closed  by  through-and-through  sutures  of  silkworm 
gut. 

Oct.  17.     Much  vomiting. 

Oct.  19.     No  vomiting. 

Oct.  2g.     Sutures  removed;  wound  healed. 

Nov.  2.     Patient  allowed  to  sit  up  in  a  chair.     No  vomiting;  feels  strong. 

Nov.  9.  Patient  walking  about. 

Nov.  13.     Patient  went  home. 

The  patient  was  at  home  for  ten  days  when  she  again  began  to  vomit  as  before:  in 
the  morning  bile;  later  in  the  day  particles  of  food;  would  vomit  two  or  three  times  every 
day.  On  re-admission  her  nutrition  was  good.  On  the  abdomen  were  two  scars  of  former 
operations.     Slight  distension  of  the  stomach. 

Fifth  Operation,  Dec.  7,  1903.  An  incision  seven  inches  long  was  made,  dissecting  out 
the  last  cicatrix.  On  opening  the  peritoneum  many  adhesions  were  found  between  intes- 
tines and  under  surface  of  incision  Universal  adhesions  were  present  throughout  the 
intestinal  canal;  these  were  carefully  dissected  free,  and  two  holes  in  the  intestine,  which 
were  accidentally  made,  were  closed  with  sutures  of  silk.  Abdomen  was  filled  with  salt 
solution,  and  wound  closed  with  through-and-through  sutures  of  silkworm  gut. 

Jan.  14, 1904.  Patient  apparently  entirely  well.  She  remained  in  good  health  for  one 
year,  and  then  died  of  unknown  cause,  but  with  no  gastric  symptoms. 

This  unfortunate  woman,  therefore,  had  undergone  five  operations, 
one  after  the  other,  for  the  relief  of  severe  vomiting.  An  entero- 
anastomosis  and  an  occlusion  of  the  pylorus  both  had  failed  to  relieve 
her  condition.  Every  cause  for  vicious  circle  or  for  jejunal  reflux 
seemed  to  have  been  eliminated,  except  the  influence  of  adhesions, 
which  were  encountered  at  each  operation.  The  patient  gained  in 
weight  even  while  vomiting,  indicating  that  the  digestive  power  was 
not  seriously  impaired. 

The  senior  author's  experience  with  the  vicious  circle  (up  to  1913) 
embraced  twelve  cases,  which  may  be  thus  classified: 

I.  Among  25  operations  of  posterior  gastro-  \  Eight  developed  the  vicious  circle;  5  of  these 
jejunostomy,  with  long  afferent  loop,  I      recovered,   and   3   died,   after  secondary 


and  without  primary  entero-anasto-        operations, 
mosis.  ^ 

Among  19  operations  of  posterior  gastro- 
jejunostomy with  long  afferent  loop, 
and  with  primary  entero-anastomosis 


Three  patients  (one  more  than  s  years  after 
operation;  another  nearly  S  years  after 
operation) :  two  were  cured  after  secondary 
operation,  the  third  died  after  the  second 
secondary  operation. 

3.  Among  429  operations  of  posterior  ■)  One  patient,  who  was  cured  by  a  secondary 
gastro-jejunostomy  with  "short  loop,"  [•  operation.  There  has  been  no  case  of 
or  with  "no  loop,"  (upto  Jan.  i,  1920)  J      vicious  circle  since  the  year  19 15. 

Probably  no  more  forcible  comment  is  needed  on  the  disadvantages 
of  the  long  loop  posterior  gastro-jejunostomy. 

The  eight  patients  in  the  category  where  no  primarj-  entero-anas- 
tomosis was  done,  who  developed  the  vicious  circle,  were  reoperated  on 
at  intervals  varying  from  four  days  to  one  year  after  the  primary 


VICIOUS    CIRCLE  387 

operation.  In  six  cases  an  entero-anastomosis  was  done  at  the  sec- 
ondary operation;  four  of  these  six  patients  were  thus  reheved  of  their 
symptoms,  but  the  remaining  two  patients  died  after  the  secondary 
operation  from  peritonitis  due  to  leakage  of  the  Murphy  button  em- 
ployed in  making  the  anastomosis.  The  seventh  patient  was  treated 
(April,  1904)  by  resection  with  end-to-end  anastomosis  by  suture  of  the 
distended  afferent  loop,  thus  converting  the  operation  into  one  of  the 
modern  short  loop  gastro-jejunostomies;  but  this  patient  died  two 
days  after  this  secondary  operation,  of  exhaustion.  The  last  of  these 
eight  patients  was  operated  on  for  the  vicious  circle  one  year  after 
gastro-jejunostomy  by  this  method  (posterior  long  loop,  without 
entero-anastomosis)  had  been  done  in  another  hospital  by  another 
surgeon.  In  this  patient  relief  was  obtained  by  the  performance  of  an 
entero-anastomosis,  ligation  of  the  pylorus,  and  ligation  of  the  afferent 
loop  (Fowler).  She  was  last  heard  from  more  than  two  years  after  this 
secondary  operation,  and  was  in  good  health,  and  feeling  much  better 
than  before  this  last  operation,  though  still  somewhat  troubled  by 
gastric  sjTnptoms. 

The  first  patient  who  developed  the  vicious  circle  among  the  series 
of  long  loop  gastro-jejunostomies  in  which  a  primary  entero-anastomosis 
was  done,  was  entirely  relieved  of  his  symptoms  by  a  secondary  ligation 
of  the  pylorus,  employed  three  months  after  the  primary  operation. 
He  was  last  heard  from  two  and  a  half  years  after  the  secondary  opera- 
tion, was  in  excellent  health,  and  had  no  symptoms  referable  to  the. 
stomach.  The  second  patient,  who  developed  symptoms  of  the 
vicious  circle  in  191 1  (53^^  years  after  the  original  operation)  recovered 
after  having  the  duodenum  plicated,  but  has  not  been  traced.  The 
third  patient  developed  symptoms  in  1913,  nearly  8  years  after  the 
original  operation;  it  was  found  that  the  afferent  and  efferent  jejunal 
loops  made  a  spur,  which  obstructed  the  gastro-jejunostomy  opening, 
though  the  entero-anastomosis  was  patulous  and  apparently  func- 
tionating. Release  of  some  adhesions  caused  this  spur  to  disappear. 
As  the  pylorus  was  patulous  the  duodenum  was  plicated  just  beyond  it; 
and  the  appendix  was  removed.  For  recurrence  of  symptoms  the 
abdomen  was  re-opened  a  week  later;  the  afferent  jejunal  loop  was 
sectioned,  its  gastric  end  was  closed,  and  its  duodenal  end  was  implanted 
into  the  efferent  jejunal  loop  (Y-anastomosis) ,  but  the  patient  did  not 
rally  from  the  extensive  operation. 

In  the  third  series  of  cases  (posterior  gastro-jejunostomy  with  a 
short  loop),  there  was  one  patient,  operated  on  in  December,  1905, 
who  developed  regurgitant  vomiting.     Five  months  later  it  was  found 


388  COMPLICATIONS    AND    SEQUELS    OF    OPERATIONS 

at  the  secondary  operation  that  the  gastro-jejunostomy  opening  was 
patent;  that  the  pylorus  was  obstructed,  but  that  the  short  proximal 
loop  did  not  appear  to  be  draining  well.  Finney's  pyloroplasty  was 
therefore  done,  as  well  as  an  entero-anastomosis  between  the  short 
afferent  loop  and  the  efferent  loop  of  the  jejunum.  Recovery  was 
uneventful;  but  although  the  regurgitant  vomiting  was  reUeved,  the 
patient  when  last  heard  from,  over  two  years  later,  could  only  be 
classed  among  those  "much  improved"  by  operation.  In  looking 
back  at  this  case  it  seems  not  impossible  that  it  was  one  of  those  in 
which,  as  pointed  out  by  ^layo  (1908),  the  jejunum  has  attached  to  it 
for  some  distance  from  its  origin  a  peritoneal  fold  running  from  the 
transverse  mesocolon,  and  that  owing  to  failure  to  recognize  this 
anomaly,  the  operation  instead  of  being  a  short  loop  gastro-jejunostomy 
became  in  reality  a  long  loop  operation.  Similar  cases  have  been 
encountered  since,  but  in  these  the  peritoneal  fold  was  recognized, 
divided,  as  recommended  by  Mayo,  and  the  usual  operation  done,  with 
the  usual  satisfactory  result. 

In  common  with  all  surgeons  who  did  stomach  surgery  as  long  as 
twenty  five  or  more  years  ago,  the  senior  author's  earliest  gastro- 
jejunostomies (for  carcinoma)  were  done  on  the  anterior  wall  of  the 
stomach,  by  means  of  the  Murphy  button.  It  was  not  long,  however, 
until  the  posterior  operation  was  adopted,  still  employing  the  IMurphy 
button.  In  the  anterior  operation  a  long  afferent  loop  of  jejunum  is 
obligatory,  on  account  of  the  necessity  of  spanning  the  transverse 
colon  and  great  omentum;  and,  again  in  companj'  with  other  surgeons, 
the  senior  author  pursued  the  same  technique  in  performing  the 
posterior  operation,  not  appreciating  at  that  time  the  drawbacks  and 
the  positive  dangers  of  the  long  afferent  loop.  Believing  that  the 
regurgitant  vomiting  observed  in  some  of  these  cases  was  due  to 
obstruction  at  the  anastomotic  opening,  preventing  the  proximal  (affer- 
ent) loop  of  jejunum  from  freely  emptying  itself  into  the  distal  (effer- 
ent) loop,  the  technique  was  then  changed  so  as  to  include  at  every 
primary  operation  an  entero-anastomosis  between  the  afferent  and 
efferent  loops,  thus  making  sure  that  obstruction  to  the  afferent  loop 
could  not  exist.  This  method  proved  for  a  long  time  satisfactory, 
although  its  performance  consumed  more  time  than  the  simple  gastro- 
jejunostomy alone.  To  make  this  additional  time  as  short  as  possible, 
a  Murphy  button  was  at  first  employed  in  making  the  entero-anasto- 
mosis, but  when  disaster  directly  traceable  to  the  use  of  the  Murphy 
button  occurred,  this  method  was  abandoned,  and  since  that  time 
simple  sutures  have  been  employed. 


VICIOUS    CIRCLE  389 

Even  while  employing  the  method  of  posterior  gastro-jejunostomy 
with  the  long  loop  and  entero-anastomosis,  we  were,  of  course,  quite 
well  aware  of  the  brilliant  results  of  other  surgeons  from  the  "short 
loop"  and  the  "no-loop"  operations;  but  as  long  as  the  technique 
being  employed  proved  satisfactory,  it  seemed  poor  surgery  to  change 
that  technique  merely  to  keep  in  fashion.  In  the  course  of  time, 
however,  it  came  to  pass  that  a  patient  on  whom  this  operation  had 
been  done,  returned  with  the  vicious  circle.  This  patient,  as  already 
described,  was  entirely  reheved  of  his  symptoms  by  ligation  of  the 
pylorus.  Since  that  time  the  short  loop  or  "no  loop"  operation  has 
been  employed,  and  the  vicious  circle  is  now  never  a  sequel  of  the 
operation. 

We  would  recommend,  therefore,  the  following  course  in  the  opera- 
tive treatment  of  the  vicious  circle,  following  posterior  gastro-jejun- 
ostomy with  long  afferent  loop :  .    ' 

1.  Entero-enterostomy   between    the   aiTerent  and   eiTerent   limbs 

of  the  jejunal  loop.     If  this  failed  to  relieve, 

2.  Ligation  of  the  pylorus  should  be  the  next  step,  while 

3.  Occlusion  of  the  afferent  loop  between  the  entero-anastomosis 

and  the  gastro-jejunostomy  may  be  done  as  a  final  step. 

Should  for  any  reason  the  performance  of  entero-enterostomy  be 
peculiarly  difficult,  probably  the  next  step  would  be  to  divide  the 
afferent  loop  close  to  the  gastro-jejunostomy,  suture  its  gastric  end, 
and  implant  the  proximal  coil  (afferent  loop)  into  the  jejunum  at 
least  eight  inches  below  the  gastro-jejunostomy.  This  would  sup- 
plant the  lateral  anastomosis  by  a  posterior  gastro-jejunostomy  in-Y, 
according  to  the  method  of  Roux.  Kausch  (1903)  adopted  the  plan 
of  anastomosing  the  efferent  jejunal  loop  with  the  duodenum  in  its 
retroperitoneal  portion  but  the  patient  died  from  pulmonary  com- 
phcations.  Noetzel  (1912)  however  reported  a  case  in  which  this 
method  was  successful  in  relieving  a  vicious  circle. 

III.  Gastro-jejunal  and  Jejunal  Ulcer.^It  is  probable  that  ulcers 
occurring  in  the  jejunum  near  the  gastro-intestinal  anastomosis  are 
closely  related  etiologically  to  those  which  develop  at  the  gastro- 
enterostomy site  itself,  and  which  often  are  spoken  of  as  "marginnl 
ulcers."  We  can  see  no  very  good  reason  for  separating  these  two 
types  of  ulcer  pathogenetically,  though,  as  will  be  seen  below,  their 
symptomatology  is  usually  distinct.  Attention  was  formerly  centered 
on  the  jejunal  ulcers,  since  these  called  for  active  intervention 
because  of  perforation  into  the  peritoneal  cavity;  and  probably  because 


'39°  COMPLICATIONS    AND    SEQUELS    OF    OPERATIONS 

they  were  formerly  relatively  more  frequent  than  the  marginal  ulcers, 
since  many  more  anterior  than  posterior  gastro-jejunostomies  were 
done  in  the  early  period  of  gastric  surgery,  and  it  is  a  well  ascertained 
fact  that  jejunal  ulcer  is  rarer  than  gastrojejunal  ulcer  when  the 
posterior  no-loop  operation  is  employed. 

According  to  Gosset  (iqo6),  it  was  not  until  1899  (seventeen  years 
after  the  operation  of  gastro-jejunostomy  was  first  performed),  that 
Braun  reported  the  first  case  of  peptic  jejunal  ulcer,  which  in  his 
patient  developed  one  year  after  gastro-jejunostomy.  The  first  French 
case  was  reported  by  Quenu  in  1902,  and  the  first  in  England  by  Mayo 
Robson  in  1904.  Hamann  (1907)  appears  to  have  been  the  first  in 
America.  Moynihan  (1908)  collected  60  cases  of  jejunal  ulcer  following 
gastrojejunostomy.  But  the  recognition  of  gastrojejunal  ulcers  (the 
so-called  marginal  ulcer)  is  due  largely  to  the  writings  of  Paterson 
(1909),  W.  J.  Mayo  (1910)  and  Carman  and  Balfour  (1915). 

We  quoted  figures  in  the  first  edition  of  this  work  (1909)  showing 
that  jejunal  ulcer  occurred  in  less  than  one  per  cent,  of  gastro-jeju- 
nostomies, without  regard  to  the  special  technique  adopted;  and 
another  set  of  statistics,  of  more  recent  operations,  numbering  3869, 
shows  that  only  in  29  cases  did  a  jejunal  or  gastrojejunal  ulcer  develop 
or  about  in  0.75  per  cent. 

The  whole  subject  was  reviewed  in  1915  by  Lieblein,  who,  after 
excluding  all  doubtful  cases,  admitted  129  which  he  regarded  as  certain, 
79  of  which  were  jejunal  ulcers,  and  50  gastro-jejunal.  Wright  (1919) 
admits  142  proved  cases  to  his  tables  (75  or  52  per  cent,  were  jejunal,  63 
or  44.3  per  cent,  were  gastrojejunal,  and  in  4  the  ulcer's  location  was  not 
stated).  As  to  the  influence  of  the  t^pe  of  the  preceding  operation 
on  the  development  of  this  complication,  Lieblein  quotes  Von  Roojen's 
figures.  This  author  collected  189  anterior  gastro-jejunostomies  with 
6  gastrojejunal  or  jejunal  ulcers;  while  among  444  posterior  gastro- 
jejunostomies he  found  only  4  cases  of  jejunal  ulcer  developed. 

Jejunal  Ulcer  was  formerly  attributed  to  the  action  of  the  hyperacid 
gastric  secretions  on  a  portion  of  the  intestinal  canal  insufficiently 
protected  by  the  alkahne  secretions  which  exist  in  the  duodenum;  and 
the  greater  freqeuncy  of  such  ulcers  after  anterior  gastro-jejunostomy 
and  after  posterior  long  loop  operations  in  which  no  entero-anastomosis 
was  done,  certainly  seemed  to  support  this  theory.  Robson  observed 
one  case  of  jejunal  ulcer  among  30  anterior  gastro-jejunostomies,  but 
he  did  not  have  it  occur  at  all  among  300  modern  posterior  operations. 
Moreover,  this  complication  had  been  noted  (Connell,  1908)  only  once 
(Lennander)    after   gastro-jejunostomy  for  cancer,   in   which   disease 


JEJUNAL   ULCER  391 

gastric  acidity  is  absent  or  much  diminished.  Another  case  following 
gastrectomy  for  carcinoma  has  been  recorded  by  V.  Pauchet  (1920). 
But  it  must  be  acknowledged  that  most  patients  with  cancer  probably 
do  not  live  long  enough  for  this  complication  to  be  noted.  And  we 
think  surgeons,  and  perhaps  pathologists  also,  do  not  sufficiently  realize 
that  peptic  ulcer,  whether  in  the  stomach,  the  duodenum,  or  the  jeju- 
num, is  possibly  as  much  a  symptom  of  disease  as  a  disease  itself;  in 
the  same  way  that  the  ulcerated  Peyerian  patches  of  typhoid  fever  do 
not  themselves  constitute  the  whole  of  the  disease.  Thus  it  is  not 
beyond  the  bounds  of  possibility  for  future  experience  to  show  that 
peptic  ulcers  of  the  jejunum  may  exist  in  immature  state  (hemorrhagic 
ecchymosis,  exulceratio  simplex,  etc.),  in  some  patients  with  gastric 
ulcer,  even  at  the  time  of  operation;  and  that  therefore  the  subsequent 
development  of  perforating  or  hemorrhagic  ulcers  may  occur  in  spite 
of,  and  not  in  consequence  of,  the  gastro-jejunostomy.^  As  Lieblein 
points  out,  there  is  no  actual  proof  that  gastric  acidity  causes  the  ulcer; 
and  more  than  one  ulcer  (as  many  as  four  or  five)  may  exist. 

Symptoms  may  arise  within  a  few  days  or  not  for  many  years.  The 
shortest  interval  was  ten  days;  while  several  cases  have  not  developed 
until  7  years  after  the  primary  operation.  Perforation  is  frequently 
the  first  symptom;  but  in  other  cases  subacute  or  chronic  perforation 
occurs,  and  the  patients  return  complaining  of  a  recurrence  of  gastric 
symptoms. 

Of  the  79  jejunal  ulcers  studied  by  Leiblein,  perforation  into  the  free 
peritoneal  cavity  occurred  in  24  cases  (30  per  cent.),  while  the  remainder 
(S5  cases,  70  per  cent.)  ran  a  chronic  course.  In  13  cases  an  internal 
fistula  developed:  10  jejuno-coUc  fistulae,  i  gastro-coUc  fistula,  and  2 
jejuno-gastro-colic  fistulae.  Only  6  patients  survived  among  the  24 
cases  of  acute  perforation;  all  6  who  recovered  were  operated  on,  as 
well  as  3  patients  who  died,  a  mortality  of  33  per  cent,  for  those  treated 
by  operation,  compared  with  a  mortality  of  100  per  cent,  among  those 
in  whom  no  operation  was  done.  Among  the  chronic  cases  there  were 
many  operations,  and  all  but  i8  patients  had  to  have  more  than  one 
operation  (several  had  3  or  4  operations),  and  some  had  recurrence  of 
symptoms  as  long  as  5  years  after  the  operation  for  jejunal  ulcer.     Thus 

'  Blanc  and  Mosse  (1908)  narrated  the  history  of  a  patient  with  symptoms  resembling 
pyloric  obstruction  which  were  found  at  operation  to  be  due  to  stenosis  of  the  upper  jejunum 
from  ulceration;  and  Schwarz  (1914)  observed  a  stenosing  jejunal  ulcer  in  a  boy  10  years 
of  age,  on  whom  he  was  doing  gastro-jejunostomy  for  pyloric  obstruction.  Ulcers  of  the 
jejunum  not  sequels  of  gastro-jejunostomy  were  well  studied  in  191 3  by  Cade,  Rouhier,  and 
Martin  and  by  Leotta  in  1919,  who  collected  22  such  cases  involving  the  jejunum  or 
ileum. 


392  COMPLICATIONS   AND    SEQUELS    OF    OPERATIONS  ■ 

it  is  evident  that  treatment  of  jejunal  ulcer  has  not  been  very  satis- 
factory on  the  whole.  The  simplest  of  the  radical  operations  for  these 
chronic  cases,  according  to  Lieblein  (suture  of  a  perforation  discovered 
on  separating  adhesions)  had  no  mortality,  and  the  end  results  though 
not  brillant  were  better  than  after  such  palliative  operations  as  estab- 
lishing a  jejunal  fistula  or  making  a  new  gastro-jejunostomy.  The 
ulcer  was  resected  in  15  cases,  with  3  deaths. 

Gastro-jejunal  Ulcer. — Paterson  (1909),  Mayo  (1910)  and  others 
have  blamed  this  complication  on  faulty  operating  defects  in  tech- 
nique) ;  but  to  us  it  does  not  seem  just  to  lay  the  blame  for  all  gastro- 
jejunal  ulcers  solely  on  the  operator:  the  stomach  is  diseased,  and  what- 
ever be  the  real  cause  of  gastric  ulcer,  it  probably  is  not  removed  by 
gastro-jejunostomy  alone;  so  that  development  of  an  ulcer  at  the  site 
of  anastomosis  or  elsewhere  may  in  many  cases  be  properly  attributed, 
we  believe,  to  the  underlying  disease.  However,  this  view  does  not 
absolve  the  surgeon  from  performing  the  anastomosis  with  the  utmost 
attention  to  the  details  of  suture;  and  it  is  above  all  things  important 
to  impress  on  the  patient  the  fact  that  operation  is  only  one  step  in  the 
cure  of  gastric  ulcer — that,  as  has  often  been  pointed  out,  operation  is 
often  only  a  mechanical  device  to  allow  medical,  dietectic  and  other 
chemical  measures  to  become  effective.  If  this  fact  were  constantly 
borne  in  mind,  indiscretions  and  negligences  in  diet  and  in  oral  hygiene 
would  be  less  apt  to  occur,  and  the  possibility  of  jejunal  or  gastro- 
jejunal  ulcer  developing  would  be  correspondingly  diminished. 

The  influence  of  non-absorbable  suture  material,  used  as  a  through- 
and-through  suture,  in  causing  ulceration,  was  noted  by  Key  (Berg's  case) 
in  1907,  and  in  1910  by  Mayo;  but  altogether  too  much  stress  has  been 
laid  on  this  lapse  in  technique,  for  as  such  we  regard  it — only  absorb- 
able suture  material  being  suitable  in  our  opinion  for  through-and- 
through  intestinal  sutures.  In  the  majority  of  cases  of  gastro-jejunal 
ulcer  which  have  come  under  our  own  observation  there  was  no  evidence 
of  an  unabsorbed  suture  trying  to  ulcerate  its  way  into  the  lumen  of  the 
bowel;  and  in  Woolsey's  case  (1917),  explored  two  years  after  pri- 
mary operation,  though  a  non-absorbable  suture  hung  free  in  the 
anastomosis  there  was  no  ulcer. 

The  presence  of  an  ulcer  at  the  site  of  anastomosis  can  rarely  be 
certainly  diagnosticated,  though  roentgen-ray  studies,  as  [)ointed  out 
by  Carman  and  Balfour  (1915)  may  show  irregularity  at  the  site  of 
anastomosis  or  stricture  of  the  jejunum  just  beyond  it.  The  patients 
return  complaining  usually  of  a  recurrence  of  the  symptoms  for  the 
relief  of  which  the  original  operation  was  undertaken.     Of  the  50  cases 


GASTRO-JEJCJNAL    ULCER  393 

studied  by  Lieblein  (1915),  perforation  into  the  free  peritoneal  cavity 
occurred  only  in  6  (12  per  cent.),  compared  with  30  per  cent,  of  acute 
perforations  among  the  cases  of  jejunal  ulcer.  The  free  interval 
following  the  gastro-jejunostomy  was  from  4  weeks  to  7  years.  Five 
patients  with  acute  perforation  of  gastro-jejunal  ulcers  were  operated 
on  with  4  recoveries;  the  only  patient  who  was  not  operated  on,  died. 
In  44  cases  the  course  of  the  gastro-jejunal  ulcer  was  chronic,  and  in  21 
of  these  cases  a  tumor  mass  formed,  palpable  either  before  operation 
(to  the  left  of  the  umbilicus  or  in  the  left  hypochondrium)  or  after 
opening  the  abdomen.  The  free  interval  varied  from  a  few  months  to 
8  years.  In  10  of  these  44  cases  obstruction  was  the  predominating 
feature;  and  in  4  cases  a  gastro-colic  fistula  formed. 

Wright's  (1919)  study  indicated  that  19  patients  died  without 
re-operation;  19  died  after  the  re-operation;  25  were  not  improved  by 
re-operation;  and  82  were  relieved  by  re-operation. 

The  operation  for  the  relief  of  gastro-jejunal  ulcer  may  prove  very 
difficult,  especially  when  the  ulcer  follows  the  posterior  operation,  when 
the  parts  are  buried  in  adhesions,  and  subacute  or  chronic  perforations 
may  be  uncovered  when  least  expected.  Figure  128,  after  a  sketch 
and  anatomical  preparation  by  the  junior  author,  from  a  patient  under 
his  care  in  the  Episcopal  Hospital,  well  shows  what  may  be  encountered. 
Usually  the  best  course  to  pursue,  is  to  resect  the  entire  anastomosis, 
and  establish  a  new  gastro-jejunostomy  as  nearly  as  may  be  at  the 
same  site.  In  cases  of  posterior  no-loop  gastro-jejunostomy,  however, 
this  may  require  removal  of  so  much  of  the  proximal  jejunum  as  to 
necessitate  anastomosis  of  a  lower  coil  of  jejunum  to  the  stomach 
with  termino-lateral  implantation  of  the  afferent  into  the  efferent  loop; 
or  even  Kausch's  method  (p.  389)  of  duodeno-jejunostomy  may  have  to 
be  employed  to  secure  drainage  of  the  duodenum  if  excision  and  suture  ■ 
of  the  proximal  jejunum  causes  marked  stenosis  of  the  latter.  Pauchet 
(1920),  who  has  operated  on  10  patients,  says  the  best  operation,  if  the 
patient  is  strong  enough,  is  to  resect  the  jejunum,  reestablishing  its 
lumen  by  end-to-end  anastomosis;  then  do  partial  gastrectomy,  in- 
cluding the  site  of  the  former  anastomosis  in  the  portion  of  stomach 
removed;  and,  finally  to  implant  the  stomach  (as  in  Polya's  technique), 
into  the  jejunum  about  10  cm.  below  where  the  latter  was  resected. 

Moynihan  (1920)  reports  27  operations  for  jejunal  or  gastro-jejunal 
ulcer,  with  2  deaths  (7.4  per  cent.) ;  the  Mayo  Clinic  (St.  Mary's  Hospital 
Reports,  1918-1919)  records  34  recent  operations  for  these  lesions, 
with  only  i  death. 

The  senior  author  has  done  6  operations  (on  four  patients)   for 


394 


COMPLICATIONS    AXD    SEQUELS    OF   OPERATIONS 


gastro-jejunal  ulcer,  as  well  as  one  operation  for  an  ulcer  developing 
in  the  anastomosis  of  a  gastro-gastrostomy  for  hour-glass  stomach 
9  years  after  the  primary  operation.  A  summary  of  these  cases  is 
appended : 

Case  i.     In  191 5  posterior  gastro-jejunostomy  by  another  surgeon 
for  duodenal  ulcer. 


Fig.  128. — Gastro-jejunal  Ulcer  Following  Posterior  "No-loop"  Gastrojejunostomy 
Done  Previously  by  Another  Surgeon.  Gauze  has  been  Passed  Beneath  the  Anastomosis 
the  Interior  of  which  is  E.iposed  by  an  Incision  in  the  Jejunum  (Efferent  Loop).  Note  the 
Chronic  Ulcer  at  the  Left  of  the  Anastomosis,  and  the  Chronic  Perforation  (Gauze  Showing 
Through)  at  the  Right.  Treated  by  Resection  and  a  New  Gastrojejunostomy.  Re- 
covery; but  Death  Followed  a  Subsequent  Operation  (Presumably  for  Recurrence)  Two 
Years  Later,  after  the  Patient's  Return  to  his  Home  in  Austria.  From  a  Patient  Under 
the  Junior  Author's  Care  in  the  Episcopal  Hospital. 


Oct.  16,  1917,  excision  of  anastomosis  and  Rou.x  Y-gastro-jejunos- 
tomy  at  Lankenau  Hospital  for  gastro-jejunal  ulcer. 

April  24,  1919.  Anterior  gastro-jejunostomy  at  Lankenau  Hos- 
pital for  recurrence  of  gastro-jejunal  ulcer. 


GASTRO-JEJUNAL   ULCER 


395 


Patient  cannot  be  traced. 

Case  2.  In  1914  posterior  gastro-jejunostomy  by  another  surgeon 
for  gastric  ulcer. 


Pig.  129. — Specimen  Secured  by  Partial  Gastrectomy  in  a  Case  in  wliich  a  Marginal 
Ulcer  Developed  9  Years  after  Gastro-gastrostomy  for  Hour-glass  Stomach.  The 
Anterior  Wall  of  the  Stomach  has  been  Opened. 

Aug.  15,   191 7,  subtotal  gastrectomy  and  Roux  Y-gastro-jejunos- 
tomy  at  Lankenau  Hospital  for  gastro-jejunal  ulcer. 


ft 


Fig.   130. — Posterior  View  of  the  Specimen  Shown  in  Pig.  129.     From  a  Patient   Under 
the  Senior  Author's  Care  in  the  Lankenau  Hospital. 

Jan.  28,  1919,  suture  of  acute  perforation  of  gastro-jejunal  ulcer 
at  Lankneau  Hospital. 

Jan.  5,  1920  reports  in  good  health,  no  local  symptoms. 


396 


COMPLICATIONS   AND    SEQUELS    OF    OPERATIONS 


Case  3,  Nov.  19,  1913,  posterior  gastro-jejunostomy  by  another 
surgeon  for  perforation  of  duodenal  ulcer. 

In  191 5.  unknown  operation  on  stomach  by  another  surgeon  for 
"peptic  ulcer." 

jNIarch  3,  1916,  subtotal  gastrectomy,  posterior  gastro-jejunostomy 
and  entero-enterostomy  at  Lankenau  Hospital  for  gastro-jejunal 
ulcer. 

Dec.  15.  1917,  reports  in  excellent  health. 

Case  4.  April  8, 19 15.  posterior  gastro-jejunostomy  and  pUcation  of 
duodenum  for  ulcer,  at  Lankenau  Hospital. 

Feb.  8,  19 1 7.  resection  of  gastro-jejunal  ulcer,  and  a  new  posterior 
gastro-jejunostomy  established  at  Lankenau  Hospital. 
Jan.  I,  1918,  reports  in  excellent  health. 

Case  5.  March  26,  1907.  gastro-gastrostomyatLankenau  Hospital 
for  hour-glass  stomach  (incidental  cholescystostomy). 

April  13,  1916,  subtotal  gastrectomy,  posterior  gastro-jejunostomy 
and  entero-enterostomy  for  ulcer  at  anastomosis.  Figs.  129  and  130 
represent  the  specimen  secured  by  partial  gastrectomy. 

Died  3  months  after  operation  from  pulmonary  tuberculosis. 

rV.  Internal  Hernia  after 
Gastro-jejunostomy. — This  com- 
plication is  rarely  observed,  (a) 
Hernia  between  the  ajfferent  loop 
and  the  mesocolon.  Moschcowitz 
and  Wilensky  (191 5)  collected  8 
cases  of  this  nature,  including  one 
of  their  own  (Fig.  131) ;  and  Bryan 
(1920)  adds  a  ninth  case  while  the 
case  mentioned  in  the  first  edition 
of  this  work  as  seen  by  the  junior 
author  in  1902  (in  Harte's  service 
at  the  Episcopal  Hospital)  makes 
the  tenth  case.  In  4  of  these  in- 
stances the  comphcation  occurred 
after  a  posterior  short-loop  or  no- 
loop  operation;  in  2  after  anterior 
gastro-jejunostomy;  in  2  after  a 
posterior  long-loop  operation;  and  in  i  case  (Gorden,  1905)  the  nature  of 
the  gastro-jejunostomy  is  not  described.  The  bowel  may  enter  the 
jejuno-mesocohc  space  either  from  the  right  or  the  left.  Moschcowitz 
and  Wilensky  advise  that  the  afferent  loop  should  always  be  sutured 


Fig.    131. — Internal    Hernia   after   Gastro 
jejunostomy.     {Moschcowitz' s  Case.) 


GASTRIC   FISTULA  397 

to  the  apposed  under  layer  of  the  transverse  meso-colon,  at  the 
original  operation. 

Even  without  an  actual  hernia,  the  long  loop  has  been  responsible 
for  death  in  a  small  number  of  cases  by  producing  obstruction  through 
volvulus  of  the  anastomosed  loop,  or  by  drawing  the  mesentery  so  taut 
as  to  strangluate  the  lower  bowel  beneath  it. 

{b)  Another  sequel,  which  has  followed  transmesocolic  operations, 
is  the  occurrence  of  a  hernia  through  the  opening  in  the  trasnverse 
mesocolon  into  the  lesser  peritoneal  cavity.  Hartmann,  Moynihan, 
and  Harte  have  each  had  such  a  case;  but  since  the  possibility  of  such 
an  event  has  been  recognized  its  occurrence  has  been  prevented  by  the 
nearly  universal  custom  of  suturing  the  edges  of  the  mesocolic  opening 
around  the  gastro-intestinal  anastomosis. 

V.  Gastric  Fistulae. — These  are  classified  by  systematic  writers 
as  the  Internal  and  the  External  varieties. 

External  Gastric  Fistula  (Gastro-cutaneous  Fistula). — ^Lieblein 
and  Hilgenreiner  in  1905  found  more  than  120  cases  of  this  unusual 
affection  recorded  and  Hilgenreiner  (1913)  subsequently  collected  40 
more  cases.  This  sequel  may  follow  either  lesions  of  the  stomach 
itself,  or  affections  of  neighboring  organs.     Among  the  causes  are: 

1.  Traumatisms. — Stab  or  gunshot  wounds  (as  in  Beaumont's 
patient,  Alexis  St.  Martin)  were  more  apt  to  be  followed  by  the 
development  of  a  gastro-cutaneous  fistula  in  former  times  when  pa- 
tients were  left  either  to  die  of  themselves,  or  to  recover  in  such  condi- 
tion as  might  be  determined  by  the  natural  course  of  events.  At 
present,  when  practically  all  such  cases  are  subjected  to  immediate 
operation,  this  sequel  is  very  rare.  The  stomach  may  also  be  perfor- 
ated from  within  by  foreign  bodies  which  have  been  swallowed.  Lie- 
blein  and  Hilgenreiner  refer  to  two  such  cases. 

2.  Gastric  ulcer  is  one  of  the  recognized  causes  of  this  condition. 
It  may  result  from  perforation  when  the  stomach  is  adherent  to  the 
abdominal  parietes,  or  secondarily  through  the  external  rupture  of  a 
perigastric  abscess. 

3.  Carcinoma  of  the  stomach  was  noted  as  the  cause  in  26  cases 
among  those  collected  by  Lieblein  and  Hilgenreiner.  As  with  ulcer, 
cancer  may  directly  implicate  the  abdominal  wall,  or  a  perigastric 
abscess  may  form  first.  It  is  also  possible  for  secondary  growths  in 
the  skin,  especially  at  the  umbilicus,  to  perforate  the  stomach. 

4.  Strangulated  hernia  is  a  very  much  less  frequent  cause  of  gas- 
tric than  it  is  of  intestinal  (fecal)  fistula. 

Among  diseases  of  neighboring  structures,  which  may  cause  fis- 


398  COMPLICATIONS   AND    SEQUELS    OF    OPERATIONS 

tulous  tracts  to  form  between  the  stomach  and  the  integument,  must 
be  mentioned,  besides  inflammatory  and  malignant  diseases  of  the 
abdominal  wall,  affections  such  as  hepatic  and  subphrenic  abscesses; 
caries  of  the  ribs  or  sternum;  hydatid  cysts;  cysts  of  the  pancreas,  etc. 

Prophylaxis  is  better  than  cure.  In  very  many  cases  the  only 
treatment  that  can  be  attempted  will  be  palliative;  moreover,  these 
fistulas  not  infrequently  heal  of  themselves.  If  due  to  benign  disease 
(perigastric  abscess,  injury,  etc.),  an  operation  may  properly  be  under- 
taken. Billroth,  in  1877,  was  the  first  to  perform  gastrorrhaphy  for 
this  condition.  By  opening  the  peritoneal  cavit)'  to  one  side  of  the 
fistula,  and  carefully  excluding  all  surrounding  organs  by  gauze  packs, 
it  frequently  will  be  possible  to  dissect  the  fistulous  tract  free,  and  suture 
the  gastric  opening.  In  other  cases  it  may  be  better  to  attempt  the 
closure  of  the  fistula  by  freshening  its  edges,  and  transplanting  a  flap. 
Patients  who  cannot  be  properly  nourished,  on  account  of  persistent 
leakage,  may  be  treated  by  jejunostomy.  Patel's  patient  (1909) 
survived  8  months  with  the  jejunostomy. 

Internal  Gastric  Fistula. — As  the  result  of  disease  or  injury  a 
fistula  may  form  between  the  stomach  and  almost  any  neighboring 
organ,  or  even  with  another  part  of  the  stomach  itself.  The  colon 
is  most  often  involved  (gastro-colic  fistula) ;  but  communications  have 
been  recorded  with  the  duodenum,  esophagus,  small  intestine,  gall- 
bladder; and  fistulous  tracts  leading  to  structures  within  the  thorax 
(lung,  heart)  have  been  observed  occasionally.  The  majority  of 
these  rare  sequels  of  gastric  disease  are  of  pathological  interest  only. 
A  few,  however,  may  be  benefited  by  surgical  treatment.  Their  patho- 
genesis is  much  the  same  as  in  the  case  of  the  external  fistulae. 

Gastro-colic  Fistula. — ^Lieblein  and  Hilgenreiner  collected  95  cases 
of  this  form  of  internal  gastric  fistula.  The  cause  was  recorded  in  65  of 
the  84  cases  studied  by  Chavannaz  (1907):  47  were  due  to  carcinoma 
(38  to  gastric,  6  to  colic  cancer,  the  site  in  3  cases  not  being  recorded) ; 
II  were  due  to  ulcer  (7  certainly,  4  only  probably);  5  were  the  result  of 
tuberculous  disease  of  the  stomach  or  colon;  and  2  followed  the  forma- 
tion of  perigastric  abscess.  Its  occurrence  in  connection  with  gastro- 
jejunal  ulcer  was  mentioned  at  p.  391 . 

The  symptoms  are  fecal  vomiting  and  lienteric  diarrhea.  The 
ingested  food,  especially  such  articles  as  vermicelli,  quickly  appear 
in  the  stools  and  the  similarity  of  the  vomitus  and  the  dejections  is 
an  important  sign. 

The  diagnosis  may  be  confirmed  by  roentgenological  examination, 
or  should  this  be  unavailable,  by  distending  the  colon  or  the  stomach 


GASTRIC-COLIC   FISTULA  399 

with  air,  and  finding  that  the  organ  in  communication  becomes  dis- 
tended at  the  same  time;  or  injection  of  colored  fluids  may  be  tried. 
Such  tests  are  more  apt  to  be  successful  when  made  through  the  bowel. 

The  prognosis,  without  operation,  is  gloomy.  Chavannaz  refers 
to  two  cases  in  which  the  iistula  is  said  to  have  closed  spontaneously, 
but   neither  patient  was  traced  long  afterward. 

Palliative  treatment  consists  in  administering  opiates  or  purgatives 
accordingly  as  there  is  diarrhea  or  constipation. 

Surgical  treatment  has  been  undertaken  in  a  number  of  patients. 
Six  of  the  operations  consisted,  according  to  Chavannaz,  in  opening  a 
perigastric  abscess  (2  patients),  exploratory  laparotomy  (3  patients), 
or  gastrotomy  (i  patient).  The  operations  of  greater  interest  may  be 
thus  classified : 

1.  Colostomy.  This  operation  is  only  palUative,  and  may  be  un- 
dertaken as  a  last  resort  to  check  fecal  vomiting,  by  providing  a  false 
anus  proximal  to  the  gastro-colic  fistula.  The  emaciation  due  to 
escape  of  food  directly  from  the  stomach  into  the  colon  would  not 
be  prevented.  This  operation  was  employed  in  one  patient  (Edmunds, 
1884);  no  improvement  resulted  and  death  occurred  15  days  later, 
the  patient  also  having  cancer  of  the  rectum. 

2.  Jejunostomy.  This  operation  is  also  merely  palliative,  but 
in  cases  of  extreme  emaciation  would  be  of  slightly  more  value  than 
colostomy.  It  was  employed  by  Labhardt  and  Eiselsberg  (1901);  the 
patient  probably  had  cancer,  but  improved,  and  returned  to  his  home 
one  month  later. 

3.  Separation  of  stomach  from  colon,  with  suture  of  orifices.  This 
has  been  employed  in  a  number  of  cases,  of  which  the  following  four 
will  serve  as  examples:  (i)  Fischer,  1888:  resection  of  abdominal  wall, 
of  anterior  wall  of  stomach,  and  of  transverse  colon;  implantation  of 
duodenum  into  remains  of  stomach,  and  fixation  of  both  ends  of  colon  in 
abdominal  wound,  for  carcinoma.  In  spite  of  a  secondary  growth  in  the 
liver,  noted  at  the  time  of  operation,  the  patient  recovered  from  the 
operation,  lived  five  months,  and  died  of  carcinoma  of  the  liver.  (2) 
Henschel  and  Reichel,  1894:  partial  resection  of  gastric  wall,  and  resec- 
tion of  portion  of  transverse  colon,  including  entire  lumen,  for  cancer. 
Operation  lasted  three  hours  and  a  half  and  ended  fatally.  (3)  Czerny, 
1902 :  separation  of  gastro-Jejuno-colic  fistula,  occurring  two  months 
after  posterior  gastro-jejunostomy,  with  suture  of  the  openings  of  the 
stomach  and  colon,  and  the  performance  of  a  new  gastro-jejunostomy. 
Recovery.  (4)  Kauffmann,  1905,  separation  of  the  structures  con- 
cerned in  a  gastro-jejuno-colic  fistula  (occurring  four  years  after  pos- 


400  COMPLICATIONS    AND    SEQUELS    OF    OPERATIONS 

terior  gastro-entero-anastomosis),  with  ileo-sigmoidostomy  for  stricture 
of  transverse  colon  caused  by  suture  of  the  two  perforations  in  the  colon. 
Time  of  operation,  three  hours.  Six  days  later  the  abdomen  was  again 
opened  for  symptoms  of  perforation.  These  were  found  to  be  due  to 
perforation  of  the  sigmoid  by  the  button  used  in  making  the  anastomo- 
sis.    The  patient  died  on  the  table  at  the  second  operation. 

4.  Excision  en  masse  of  the  diseased  portions  of  stomach,  colon  and 
jejunum  was  done  by  Spassokukozki  (1909),  each  viscus  being  repaired 
separately.  His  patient  recovered,  but  symptoms  of  recurrence  of  the 
original  pyloric  ulcer  soon  developed. 

5.  Exclusion  of  the  gastro-colic  listula.  This  may  be  either  a 
complete  exclusion,  or  a  simple  short-circuiting  operation,  (a)  Com- 
plete Exclusion.  Three  such  operations  are  referred  to  by  Chavan- 
naz.  (i)  Zweig  and  Hahn,  in  1900,  made  an  anastomosis  between 
the  transverse  colon  (above  the  fistula)  and  the  sigmoid,  and  then 
occluded  the  colon  on  each  side  of  the  fistula  by  a  purse-string  suture. 
Time  of  operation,  two  hours  and  a  half.  Patient  recovered  and  was  in 
was  in  good  health  three  years  later.  (2)  Unruh  and  Garre,  in  1899, 
divided  the  transverse  colon  above  and  below  the  fistula,  closed  all 
four  ends  of  the  colon,  and  then  united  the  transverse  colon  above 
the  fistula  to  the  descending  colon.  The  portion  of  the  colon  involved 
in  the  fistula  was  thus  converted  into  a  diverticulum  of  the  stomach. 
The  operation  lasted  two  hours;  the  patient  recovered,  and  was  in  good 
health  9  months  later.  (3)  KeUing,  in  1902,  divided  the  transverse 
colon  on  both  sides  of  the  fistula,  closed  the  ends  of  the  gastric  segment 
of  colon  by  purse-string  sutures,  and  did  end-to-end  anastomosis  of  the 
transverse  colon.  His  patient  recovered,  but  died  19  months  later  from 
cancer  of  the  stomach. 

(b)  Short-circuiting  was  adopted  in  two  cases  mentioned  by  Chavan- 
naz.  Labhardt  and  Garre,  in  1901,  did  a  colo-colostomy  of  the 
transverse  colon  above  and  below  the  fistula.  Their  patient  im- 
proved, and  the  fecal  vomiting  stopped.  Chavannaz,  in  1906,  united 
the  ascending  colon  to  the  sigmoid,  for  fecal  vomiting  due  to  can- 
cerous fistula.  The  vomiting  was  not  improved  and  the  patient  died 
in  fifteen  days. 

It  is  interesting  to  note  in  this  connection  that  Mauclaire  (cited  by 
Denechau,  1908)  purposely  produced  a  gastro-colic  fistula  with  the 
hope  of  relieving  severe  gastralgia  which  recurred  one  year  after 
the  performance  of  a  posterior  gastro-jejunostomy.  On  reopening  the 
patient's  abdomen,  he  found  the  gastro-jejunal  anastomosis  in  good 
condition,  and  determined  to  do  a  gastro-colic  anastomosis  because,  in  a 


DUODENAL   FISTULA  40I 

previous  similar  case,  no  benefit  had  been  derived  from  a  second 
(anterior)  gastro-jejunostomy.  In  the  present  patient  the  pylorus 
was  thickened  and  indurated,  but  there  was  no  open  ulcer.  The 
patient  was  much  improved  (I)  by  the  formation  of  the  gastro- 
colic fistula,  but  was  not  cured.  Surely  pylorectomy  would  have  been 
better. 

Jejuno-colic  Fistvila. — Gosset  (1906)  recorded  a  successful  opera- 
tion for  this  complication  caused  by  the  perforation  of  a  peptic 
jejunal  ulcer  two  years  after  posterior  gastro-jejunostomy.  He  sepa- 
rated the  jejunum  and  colon,  sutured  the  perforations,  and  did  ileo- 
sigmoidostomy  because  of  the  stricture  thus  produced  in  the  colon. 

VI.  Duodenal  Fistula. — This  extremely  fatal  complication  of 
upper  abdominal  lesions  may  follow  either  disease  or  trauma.  Among 
the  latter  must  be  included  operative  injuries,  such  as  are  sometimes 
sustained  in  operations  on  the  bile  passages  (Kraske,  Kehr,  Lilien- 
thal,  Mayo,  Fink,  Berg),  or  on  the  right  kidney  (Schede,  Cackovic, 
Hitzrot,  Thevenard).  Lieblein  and  Hilgenreiner  {1905)  referred  to 
sixteen  cases  of  duodenal  fistula,  to  which  are  to  be  added  the  cases 
subsequently  reported  by  Berg  (1907),  Hitzrot  (1910),  and  Thevenard 
(1913),  all  of  which  were  traumatic  in  origin. 

The  causes  are  various.  Perforation  of  an  ulcer  usually  has  pro- 
duced a  fistula  above  the  bile  papilla;  and  though  operative  fistulas 
are  said  to  be  more  often  seen  below  this  level,  as  are  also  fistulae  the 
result  of  rupture  or  gunshot  wounds  of  the  duodenum  (see  p.  307); 
yet  in  the  authors'  experience  these  post-operative  fistulae  also  have 
usually  been  above  the  entrance  of  the  bile  duct.  The  cutaneous 
orifice  of  the  fistula  is  frequently  in  the  right  hypochondrium,  but  if  the 
fistulous  tract  is  retro-peritoneal,  its  outer  opening  may  be  in  one  of  the 
intercostal  spaces  (Steaten,  Gross),  in  the  loin  (Hinton),  or  even  in  the 
right  inguinal  region  (Wagner) ;  in  Rintel's  case  the  fistula  was  due 
to  tuberculous  peritonitis,  and  was  at  the  umbilicus. 

The  diagnosis  can  be  made  usually  with  comparative  ease,  differ- 
entiation from  gastric  fistula,  the  only  lesion  with  which  it  is  readily 
confused,  presenting  few  difficulties. 

The  prognosis,  unless  the  fistula  is  a  sequel  of  opera tion,'^is  bad. 
Duodenal  fistulae  following  operation,  whether  from  pressure  of  a 
drainage  tube,  from  necrosis  due  to  partial  obliteration  of  the  blood 
supply,  or  to  an  injury  undiscovered  during  the  operation,  often 
heal  spontaneously.  But  if  the  fistula  is  the  result  of  duodenal  ulcera- 
tion, with  subphrenic  abscess  or  a  long  retro-peritoneal  suppurating 
tract,  emaciation  is  rapid,  and  if  the  patient  does  not  die  of  starvation, 

26 


402  COMPLICATIONS    AND    SEQUELS    OF    OPERATIONS 

he  is  liable  to  do  so  from  sepsis.  Except  for  several  post-operative 
cases,  we  know  of  no  instance  of  recover^'  from  duodenal  fistula. 

The  only  treatment  which  offers  any  hope  of  cure  is  operation. 
Traumatic  lesions  alone  are  suitable  for  suture  fduodenorrhaphy) ;  this 
was  successfully  adopted  in  one  case  by  the  senior  author,  in  addition  to 
posterior  gastro-jejunostomy.  When  the  fistula  follows  ulceration, 
and  indeed  also  in  many  post-operative  cases,  much  more  may  be  hoped 
for  from  gastro-jejunostomy  combined  with  unilateral  exclusion  of  the 
duodenum  by  hgation  of  the  pylorus.  This  operation  was  suggested 
by  Cackovic  and  by  Berg  in  1903.  Berg's  first  patient  lived  seventeen 
days;  but  in  his  second  case  he  attempted  to  suture  the  perforation  at 
the  same  time  that  he  did  gastro-jejunostomj-;  the  sutures  gave  way, 
and  then  occlusion  of  the  pylorus  was  performed  too  late  to  save  the 
patient.  The  senior  author  has  succeeded  in  bringing  about  healing 
of  the  wound  in  several  cases  by  means  of  a  pylorectomy  including 
the  duodenum  down  to  a  point  below  the  fistula ;  this  excision  of  course 
being  supplemented  by  a  posterior  gastro-jejunostomy.  By  this  tech- 
nique all  sutures  are  placed  in  healthy  tissues,  and  there  is  little  proba- 
bihty  of  the  fistula  again  forming. 

In  patients  with  extreme  emaciation  some  surgeons  have  done  je- 
junostomy  with  the  hope  of  doing  a  more  radical  operation  should 
sufficient  strength  be  gained.  Cackovic  (1903)  tried  this  plan,  but  his 
patient  died  in  two  days.  Direct  feeding,  either  through  the  fistula, 
or  through  a  duodenal  tube  introduced  by  mouth  and  allowed  to  pass 
the  fistula,  offers  a  better  expectation  of  life;  and  if  well  tolerated,  per- 
sistence in  this  latter  method  might  even  allow  the  fistula  to  close. 

Internal  Duodenal  Fistula,  i.e.,  gastro-duodenal,  duodeno-cohc 
cholecysto-duodenal,  etc.,  is  so  rare  as  to  be  of  pathological  interest 
only. 

Vn.  Subphrenic  Abscess. — This  serious  complication,  though  due 
to  a  variety  of  causes,  is  in  such  a  large  proportion  of  cases  due  to 
precedent  gastric  or  duodenal  disease,  as  to  render  it  worthy  of  rather 
extended  notice  in  this  volume. 

By  the  term  subphrenic  abscess  is  strictly  understood  only  those 
abscesses  formed  between  the  dome  of  the  diaphragm  and  some  sub- 
jacent organ;  but  as  usually  employed  the  expression  is  made  to  embrace 
practically  every  abscess  which  at  one  portion  or  other  of  its  circum- 
ference comes  into  contact  with  some  portion  of  the  diaphragm.  Thus 
an  abscess  between  the  left  lobe  of  the  Uver  and  the  anterior  gastric 
wall  is  included  among  subphrenic  abscesses  because  of  its  close  relation 
to  the  attachments  of  the  diaphragm  in  the  left  epigastric  and  hypo- 


SUBPHRENIC   ABSCESS  403 

chondriac  regions;  and  one  in  the  lesser  peritoneal  cavity  will  also  be 
included  because,  by  extending  outward  toward  the  spleen,  or  upward 
and  backward  along  the  Spigelian  lobe  of  the  liver,  it  will  come  into 
contact  with  the  diaphragm  in  those  situations. 

The  first  description  of  subphrenic  abscess,  according  to  Free- 
man (1906),  was  that  of  Barlow,  in  1845.  I^i  1862  it  was  accurately 
described  by  Bouchard;  and  the  first  operation  was  recorded  by  Volk- 
mann,  in  1879.  Maydl,  in  1894,  published  a  monograph  on  the  sub- 
ject based  on  a  study  of  179  cases.  Finkelstein  in  1899  collected  252 
cases;  Piquand  (1909)  collected  890  cases;  and  the  subject  was  fully 
discussed  by  Barnard  (1908),  to  whose  excellent  papers  we  are  glad  to 
acknowledge  our  indebtedness  in  preparing  the  present  account. 

A  study  of  the  pathogenesis  of  subphrenic  abscess  is  considerably 
simplified  by  dividing  the  area  beneath  the  diaphragm  into  certain 
definite  anatomical  regions  (Fig.  15),  as  done  by  Barnard:  "The  under 
surface  of  the  diaphragm  is  marked  out  into  four  peritoneal  spaces  and 
two  cellular  ones.  The  four  peritoneal  spaces  are  separated  from  one 
another  by  the  cruciform  arrangement  of  the  ligaments  of  the  liver — 
namely,  the  coronary,  falciform,  and  the  right  and  left  lateral  hga- 
ments.  The  falciform  ligament  divides  the  subphrenic  space  into 
two  parts,  right  and  left.  Each  of  these  is  again  subdivided  into  a 
larger  anterior  and  a  smaller  posterior  part  by  the  corresponding 
lateral  Hgament."  The  two  cellular  (extra-peritoneal)  subphrenic 
areas  are  (1)  that  included  between  the  layers  of  the  coronary  liga- 
ment; and  (2)  that  extending  from  the  cellular  tissues  around  the  upper 
pole  of  the  left  kidney  up  to  beneath  the  left  dome  of  the  diaphragm. 
Barnard  therefore  classified  the  subphrenic  fossae  thus: 

.  ,     J   I.  Anterior.      343  cases  (Piquand) 

,     -  .  ,         '  [2.  Posterior.     loi  cases  (Piquand) 

A.  Intra-pentoneai  ;  ,  ,    .     •  zn-  ji 

I  j.       f   3.  Anterior.      300  cases  (Piquand) 

I  4.  Posterior        31  cases  (Piquand) 

/  S-  Right.  132  cases  (Piquand) 

B.  E.xtra-pentoneal <    ";    ,   7  ,„. 

I.   6.  Lett.  19  cases  Iriquand) 

I.  An  abscess  in  the  right  anterior  intra-peritoneal  region  is  bounded 
above  by  the  diaphragm,  below  by  the  right  lobe  of  the  liver,  on  the 
left  by  the  falciform  ligament;  in  front  usually  by  adhesions  between 
the  hepatic  margin  and  the  anterior  abdominal  wall;  while  on  the  right 
such  an  abscess  is  frequently  continuous  with  the  right  kidney  pouch, 
from  which  direction  the  infection  has  most  often  travelled.  Of 
343  abscesses  in  this  group,  studied  by  Piquand,  very  few  were  due 
to  perforation  of  gastric  or  duodenal  ulcers;  the  great  majority  were 


404  COMPLICATIONS   AND    SEQUELS    OF    OPERATIONS 

caused  by  appendicitis  (77  cases),  or  by  hepatic  (61)  and  biliary  lesions 
(50  cases). 

2.  The  right  posterior  intra-peritoneal  region  is  continuous,  be- 
tween the  posterior  surface  of  the  right  lobe  of  the  liver  and  the  lower 
ribs,  with  the  right  kidney  pouch  and  subhepatic  fossa.  In  its  strictly 
subphrenic  region  such  an  abscess  would  be  bounded  above  by  the 
diaphragm,  below  by  the  upper  surface  of  the  posterior  portion  of  the 
right  lobe  of  the  liver,  in  front  by  the  right  lateral  ligament,  and  on  the 
left  by  the  reflection  of  parietal  peritoneum  covering  the  right  surface 
of  the  vena  cava  and  becoming  continuous  between  diaphragm  and 
liver  with  the  coronary  and  right  lateral  ligaments  of  the  liver.  Ab- 
scesses in  this  situation  also  are  commonly  due  to  infection  through 
the  right  renal  pouch,  and  thus  such  an  abscess  may  sometimes  extend 
beneath  the  right  lobe  of  the  liver,  between  it  and  the  transverse  meso- 
colon, across  the  foramen  of  Winslow  (which  easily  is  occluded  by 
plastic  peritonitis)  to  the  anterior  surface  of  the  gastro-hepatic  omen- 
tum, where  it  will  be  bounded  above  by  the  left  lobe  of  the  liver,  below 
by  the  stomach,  in  front  by  the  abdominal  wall  and  the  diaphragm. 
Of  course,  it  is  also  possible,  though  less  usual,  for  infection  to  travel 
in  the  other  direction,  starting  on  the  anterior  surface  of  the  stomach, 
passing  to  the  subhepatic  region,  up  the  posterior  abdominal  wall,  to 
become  again  finally  subphremc.  This  area  is  thus  seen  to  be  very 
large  and  irregular  in  outline:  it  includes  not  only  the  region  above  the 
right  lobe  of  the  liver,  back  of  the  right  lateral  ligament,  but  also  the 
subhepatic  space,  which  has  its  base  in  the  lateral  abdominal  wall, 
and  its  apex  between  the  left  lobe  of  the  liver  and  the  anterior  gastric 
wall.  Among  Piquand's  890  cases  of  subphrenic  abscess,  this  region 
was  involved  only  in  loi  cases;  and  in  only  47  of  these  was  the  abscess 
limited  strictly  to  this  space. 

3.  Abscess  in  the  left  anterior  intra-peritoneal  region  is  bounded 
above  by  the  diaphragm,  below  by  the  left  lobe  of  the  liver,  on  the 
right  by  the  falciform  ligament,  on  the  left  by  the  spleen,  posteriorly 
by  the  left  lateral  ligament,  and  anteriorly  by  adhesions  between  the 
anterior  surface  of  the  stomach,  the  transverse  colon,  the  great  omen- 
tum, and  the  abdominal  wall.  Below  the  anterior  margin  of  the  left 
lobe  of  the  liver  this  pouch  is  continuous  on  the  right  with  the  sub- 
hepatic pouch,  and  on  the  left  with  the  lumbar  pouch,  from  which  in- 
fection may  reach  it  by  travelUng  between  the  spleen  and  the  splenic 
flexure  of  the  colon.  This  left  anterior  intra-peritoneal  sub-diaphrag- 
matic region  is  that  which  is  most  often  invaded  by  gastric  ulcers 
which  perforate  subacutely.     Among  Piciuand's  cases,  there  were  300 


SUBPHRENIC   ABSCESS  405 

instances  of  suppuration  in  this  space,  and  1.38  of  these  abscesses  were 
due  to  gastric  perforations. 

4.  An  abscess  in  the  left  posterior  intra-peritoneal  region  arises  in 
the  lesser  peritoneal  cavity.  The  Spigelian  lobe  of  the  Hver,  which 
lies  in  the  roof  of  this  cavity  (see  p.  19),  is  in  contact  with  the  peri- 
toneum covering  the  left  crus  of  the  diaphragm.  This  portion  of  the 
lesser  peritoneal  cavity  is  usually  the  last  to  be  invaded,  so  that  fre- 
quently a  so-called  subphrenic  abscess  in  this  region  will  have  no  direct 
relation  to  the  diaphragm.  The  lesser  peritoneal  cavity  of  course 
communicates  through  the  foramen  of  Winslow  with  the  subhepatic 
pouch;  but,  as  is  well  known,  inflammatory  processes  in  this  region  tend 
to  become  encysted  by  the  early  obliteration  of  this  foramen  by 
adhesions.  It  is  very  rare  for  an  abscess  to  spearate  the  layers  of  the 
great  omentum  and  form  a  secondary  omental  abscess.  The  most 
usual  cause  of  suppuration  in  the  lesser  peritoneal  sac  is  perforation  of 
a  gastric  ulcer.  Among  Piquand's  890  cases  there  were  31  abscesses  in 
this  situation:  13  were  due  to  pancreatic  lesions.  Michel  and  Gross  in 
1904  collected  44  instances  of  suppuration  in  the  lesser  peritoneal 
cavity.  They  classified  the  causes  thus:  i.  Encysted  hemorrhage 
which  has  become  infected,  due  originally  to  pancreatitis  hemorrhagica 
or  to  trauma.  2.  Directly  from  pancreatitis.  3.  Perforation  of  the 
stomach.  4.  Diseases  of  the  spleen.  5.  General  peritonitis.  The 
junior  author  reported  (1902)  a  case  of  gastric  ulcer  in  which  perforation 
occurred  nearly  simultaneously  on  both  anterior  and  posterior  walls, 
producing  two  subphrenic  abscesses,  one  beneath  the  left  lobe  of  the 
liver,  anterior  to  the  gastro-hepatic  omentum,  and  the  other  in  the 
lesser  peritoneal  cavity. 

5.  An  abscess  in  the  right  extra-peritoneal  subphrenic  region  hes 
between  the  layers  of  the  coronary,  the  two  lateral,  and  the  falciform 
ligaments  of  the  liver.  This  form  is  due  mostly  to  abscess  of  the  liver  or 
other  forms  of  hepatic  disease;  other  recognized  causes  are  affections 
of  the  right  kidney,  retro-peritoneal  appendicular  suppurations,  retro- 
peritoneal duodenal  perforations,  and  occasionally  perforation  of  the 
diaphragm  as  the  result  of  thoracic  disease.  Such  abscesses  may  point 
in  the  epigastric  region,  or  rarely  at  the  umbilicus. 

6.  The  left  extra-peritoneal  subphrenic  region  is  usually  infected 
through  the  structures  around  the  spinal  column  or  the  left  kidney. 
Two  of  Barnard's  cases  were  due  to  acute  periosteitis  of  the  transverse 
vertebral  processes,  a  third  was  caused  by  an  empyema,  and  "the 
fourth  was  probably  due  to  a  posterior  perforating  gastric  ulcer," 
as  in  the  similar  case  described  by  Robson. 


4o6  COMPLICATIONS   AND    SEQUELS    OF    OPERATIONS 

Cause. — As  may  be  seen  from  the  preceding  paragraphs,  the  causes 
of  subphrenic  abscess  are  many  and  varied.  The  statistics  of  Lance 
(1909),  comprising  almost  a  thousand  cases,  indicate  that  about  20 
per  cent,  are  caused  by  appendicitis;  30  per  cent,  by  lesions  of  the  stom- 
ach and  duodenum;  13  per  cent,  by  lesions  of  the  liver  and  gall-bladder; 
and  37  per  cent,  by  miscellaneous  affections  (pancreas,  spleen,  large 
intestine,  pleura,  etc.). 

Pathogenesis. — We  may  then  briefly  study  the  origin  and  method 
of  infection  in  these  various  classes. 

Gastric  ulcers  most  often  perforate  anteriorly.  If  diffuse  peritonitis 
is  not  at  once  produced,  the  perforation  will  be  subacute,  protective 
adhesions  having  quickly  formed.  Under  these  circumstances  the 
resulting  abscess  will  occupy  the  apex  of  the  subhepatic  fossa,  between 
the  left  lobe  of  the  liver  above,  the  gastro-hepatic  omentum  posteriorly, 
and  the  stomach  below.  Unless  quickly  relieved,  such  an  abscess  is 
prone  to  leak,  producing  secondary  diffuse  peritonitis,  usually  of  the 
progressive  fibrino-purulent  form  described  by  MikuHcz.  If  neither 
leakage  nor  rupture  occur,  the  pus  usually  will  work  its  way  around  the 
anterior  margin  of  the  left  lobe  of  the  liver,  invade  the  left  anterior 
subphrenic  space,  and  form  a  true  subphrenic  abscess.  Although  this 
anterior  perigastric  abscess  is  almost  invariably  the  result  of  subacute 
perforation  of  a  gastric  ulcer,  it  may  occur  on  the  subsidence  of  an  un- 
operated  diffuse  peritonitis  due  to  acute  perforation.  Such  a  case  was 
observed  by  the  junior  author  under  Dr.  T.  R.  Neilson's  care  at  the 
Episcopal  Hospital  (1908).  Perforation  of  a  posterior  gastric  ulcer 
causes  suppuration  in  the  lesser  peritoneal  ca\aty;  very  rarely  has 
perforation  on  the  extraperitoneal  surface  of  the  stomach  led  to  sub- 
phrenic abscess  (J.  A.  C.  Macewen,  1920).  Eliot  (1912)  has  reported 
a  case  of  bilateral  subphrenic  abscess  due  to  duodenal  ulcer.  Sequels 
of  these  epigastric  abscesses  other  than  fatal  peritonitis  are  rare; 
but  among  the  results  which  are  occasionally  seen  may  be  mentioned 
the  various  forms  of  gastric  iistulse,  already  described  (p.  397);  and 
perforation  of  the  pleura,  the  lung,  the  pericardium,  etc. 

Duodenal  ulcers  on  perforation  infect  either  the  right  anterior 
subphrenic  region,  if  intra-peritoneal,  or  the  right  retro-peritoneal 
cellular  tissue,  if  perforation  occurs  on  the  posterior  or  internal  surface 
of  the  bowel.  Intra-peritoneal  infection  has  a  marked  tendency  to 
gravitate  to  the  right  lumbar  region,  and  by  invading  even  the  iliac 
fossa  may  simulate  appendicitis. 

Appendicitis  itself  may  give  rise  to  subphrenic  abscess  in  various 
waj's.     Elsberg  (1901)  collected  73  such  cases,  and  to  these  Eisendrath 


SUBPHRENIC   ABSCESS  407 

(1908)  added  ;^t,  others,  including  5  of  his  own.  It  occurred  in  20  out 
of  one  series  of  2400  cases  of  appendicitis  under  the  care  of  the  senior 
author,  4  patients  recovering.  Intra-peritoneal  subphrenic  abscess  is 
much  more  often  a  compUcation  of  appendicitis  than  is  extraperitoneal. 
Among  the  106  cases  analyzed  by  Eisendrath,  the  abscess  was  intra- 
peritoneal in  two-thirds.  In  the  usual  variety  the  right  renal  pouch 
is  first  affected,  then  the  right  posterior  intra-peritoneal  subphrenic 
space,  including  the  subhepatic  space,  and  finally  the  right  anterior 
subphrenic  space  may  be  invaded  around  the  right  free  extremity  of 
the  lateral  ligament  of  the  liver.  It  is  a  mistake  to  assume,  as  was  done 
by  Ross  (1911),  that  every  appendicular  abscess  in  the  right  kidney 
pouch  or  subhepatic  space  is  to  be  classed  as  a  subphrenic  abscess.  If 
the  appendix  Ues  to  the  inner  side  of  the  colon,  in  front  of  the  mesentery 
of  the  ileum  (a  very  unusual  position) ,  the  apex  of  the  subhepatic  space 
may  be  infected  directly,  without  involvement  of  the  right  renal  pouch. 
Extra-peritoneal  subphrenic  abscess  as  the  result  of  appendicitis  may 
occur  by  continuity  of  tissue,  or  secondarily  through  invasion  of  the 
liver  after  suppurative  pylephlebitis.  The  same  course  of  events 
may  of  course  occur  as  the  result  of  gastric  disease.  Eisendrath 
found  recorded  only  six  left-sided  cases  of  subphrenic  abscess  due  to 
appendicitis. 

Hepatic  abscess  frequently  becomes  subphrenic  by  the  process 
of  pointing  of  an  abscess  through  the  convex  surface  of  the  liver. 

Diagnosis. — According  to  Barnard,  in  aiming  to  arrive  at  a  diagno- 
sis in  cases  of  suspected  subphrenic  abscess,  special  attention  should 
be  paid  to  the  following  points : 

1.  The  Previous  History  of  the  Patient. — The  usual  causes  of  the 
condition,  e.g.,  gastric  or  duodenal  ulcer,  appendicitis,  hepatic  abscess, 
dysentery,  etc.,  must  be  studied. 

2.  The  Character  of  the  Onset  is  important.  If  the  symptoms  were 
acute,  the  abscess  probably  is  intra-peritoneal;  but  if  insidious  in  their 
origin  it  is  more  likely  to  be  situated  extra-peritoneally,  or  in  the  lesser 
peritoneal  cavity. 

3.  The  Constitutional  Signs  of  Pus  should  be  searched  for:  elevation 
of  temperature,  persistent,  even  if  slight;  chills;  emaciation;  thirst; 
leukocytosis;  etc.  Other  possible  regions  of  suppuration  should  be 
excluded. 

4.  Abdominal  Signs  and  Symptoms. —These  include  bulging,  im- 
mobility during  respiration;  tenderness,  rigidity;  dulness,  or  tympany 
due  to  the  perforation  of  an  air-containing  viscus.  A  swelling  due 
to  subphrenic  abscess  is  immobile  because  fixed  by  adhesions. 


408  COMPLICATIONS   AND    SEQUELS    OF    OPERATIONS 

5.  Thoracic  Signs  and  Symptoms. — These  were  present  in  56  out 
of  76  cases  of  subphrenic  abscess  studied  by  Barnard.  The  most 
important  are:  dulness,  associated  with  upward  displacement  of  the 
lung;  diminution  or  absence  of  breath  sounds,  vocal  resonance,  and 
vocal  fremitus.  Occasionally  dulness  on  percussion  may  be  associated 
with  tubular  breathing  and  increased  vocal  resonance.  Amphoric 
resonance,  the  coin  sound,  etc.,  may  be  present  in  abscesses  contain- 
ing air.  The  apex  beat  of  the  heat  may  be  displaced  upward,  but 
seldom  laterally.  Hoover  (1913)  lays  stress  on  relative  increase  or 
decrease  of  the  excursion  of  the  costal  border  on  the  affected  side,  in 
differentiating  between  subphrenic  abscess  and  empyema:  if  the 
abscess  is  subphrenic  the  diaphragm  is  so  much  arched  that  it  acts 
at  a  disadvantage  and  the  other  respiratory  muscles  (chiefly  the 
intercostals)  cause  the  excursion  of  the  costal  margin  to  be  increased; 
the  reverse  is  true  (that  is  the  excursion  of  the  costal  margin  on  the 
diseased  side  is  decreased  as  compared  with  the  healthy  side)  if  em- 
pyema is  present  and  the  diaphragm  is  depressed  to  a  plane  surface. 
However,  in  cases  of  massive  empyema  the  diaphragm  may  become 
concave  superiorly;  in  such  a  case  this  sign  no  longer  holds  good. 

6.  Localizing  Signs  should  be  looked  for  as  an  aid  to  operation. 
They  embrace  bulging;  tenderness;  increase  in  circumference  of  the 
lower  thorax  on  the  side  affected;  edema;  enlargement  of  the  veins, 
etc.  Fluoroscopic  Examination  shows  fixity  or  lessened  mobility  of 
the  diaphragm  on  the  affected  side. 

7.  Aspiration  is  dangerous  unless  followed  by  immediate  operation 
when  pus  is  found;  on  the  other  hand,  failure  to  find  pus  by  no  means 
excludes  the  presence  of  an  abscess,  but  may  cause  the  postponement 
of  an  operation  until  it  can  no  longer  be  of  benefit.  Hence  the  needle 
should  not  be  used  until  the  patient  is  on  the  operating  table  ready  for 
any  operation  that  may  seem  proper. 

Prognosis. — The  prognosis  of  subphrenic  abscess  is  bad,  no  matter 
what  the  treatment;  but  it  is  very  much  worse  if  no  operation  is  done, 
or  if  operative  treatment  is  too  long  delayed.  Among  Barnard's 
cases  there  were  64  patients  treated  by  73  operations;  of  this  number 
40  patients  recovered,  and  24  died,  a  general  mortality  of  37.5  per  cent. 
Death  resulted  in  every  patient  not  operated  upon.  Among  the  44 
cases  of  suppuration  in  the  lesser  peritoneal  cavity  collected  by  Michel 
and  Gross,  there  were  ig  patients  treated  by  operation;  all  of  those  not 
operated  upon  died,  while  of  the  others  only  9  died,  a  death  rate  of 
47.36  per  cent.  Of  the  patients  with  subphreiiic  abscess  following 
appendicitis,  studied  by  Eisendrath,  84  were  treated  by  operation 
with  23  deaths,  a  mortahty  of  27.38  per  cent.;  while  the  death  rate 


SUBPHRENIC   ABSCESS  409 

among  patients  not  operated  upon  was  over  82  per  cent.  As  already 
noted,  there  were  16  deaths  among  20  patients  under  the  senior 
author's  care,  a  mortality  of  80  per  cent. 

Barnard  concluded  that,  speaking  in  a  general  manner,  posterior 
methods  of  drainage  give  more  favorable  results  than  do  the  ante- 
rior. In  his  series  of  cases,  26  posterior  operations  were  performed, 
with  7  seven  deaths  (27  per  cent.) ;  43  anterior  operations,  with  17  deaths 
(39.5  per  cent.);  and  4  lateral,  with  3  deaths  (75  per  cent.).  He  had 
himself  performed  24  operations  on  21  patients  for  subphrenic  ab- 
scess; 15  of  these  operations  were  posterior,  with  2  deaths  (13.3  per 
cent.);  and  9  were  anterior,  with  2  deaths  (22.2  per  cent.). 

Treatment. — The  operations  for  subphrenic  abscess  may  be  classed 
in  accordance  with  Barnard's  tables,  as  anterior,  posterior,  and  lateral. 
The  former  include  abdominal  incisions,  whether  in  the  epigastrium 
or  in  one  of  the  hypochondriac  regions.  The  posterior  operations 
include  the  subpleural  and  transpleural  approaches  through  the  dia- 
phragm; they  resemble  the  usual  operations  for  hepatic  abscess,  which 
will  be  described  in  connection  with  that  lesion  in  a  subsequent  chapter 
(p.  791).  Lateral  transpleural  or  subpleural  operations  should  not  be 
attempted  unless  the  abscess  is  very  manifestly  pointing  in  the  axillary 
hne. 

When  the  existence  of  subphrenic  abscess  is  suspected,  it  is  some- 
times better,  as  pointed  out  by  Barnard,  to  delay  operation  for  three 
or  four  days  in  order  to  allow  the  abscess  to  become  more  accessible. 
This  applies  particularly  to  infections  beneath  the  right  dome  of  the 
diaphragm,  secondary  to  disease  of  the  liver.  When  the  abscess  is 
believed  to  be  in  other  situations  we  beheve  delay  to  be  dangerous,  and 
think  an  exploratory  laparotomy  should  be  undertaken  as  soon  as  the 
presence  of  pus  is  reasonably  certain,  even  though  its  exact  location 
cannot  be  pre-determined.  By  opening  the  peritoneal  cavity  and 
cautiously  disposing  gauze  packs  before  attempting  any  exploration 
whatever,  or  before  rupturing  any  adhesions,  it  usually  will  be  possible 
to  discover  the  situation  of  the  abscess,  and  then  to  approach  it 
by  the  thoracic  or  lumbar  route  should  such  a  course  be  advisable. 
Especially  dangerous  is  delay  in  those  subphrenic  or  perigastric  ab- 
scesses which  arise  as  the  localized  remains  of  a  diffuse  peritonitis 
(residual  abscesses).  In  such  cases  the  limiting  adhesions  are  never 
so  firm  as  in  subacute  or  chronic  perforations,  and  unless  the  abscess 
be  evacuated  so  soon  as  its  presence  is  detected,  it  will  be  sure  to 
break  again  and  produce  spreading  fibrino-purulent  peritonitis,  from 
which  very  few  patients  will  recover. 

The  use  of  the  exploring  needle  may  be  preferred  to  laparotomy 


4IO  COMPLICATIONS   AND    SEQUELS    OF    OPERATIONS 

when  the  patient,  prepared  for  operation,  is  on  the  operating  table, 
and  the  surgeon  has  good  reason  to  believe  that  the  abscess  is  beneath 
the  costal  margin.  Attention  to  the  known  pathogenesis  of  sub- 
phrenic abscess  will  frequently  enable  this  point  to  be  determined  with 
reasonable  certainty. 

In  all  cases  in  which  the  abscess  has  to  be  approached  by  the  ante- 
rior (abdominal)  route  it  will  be  much  safer  for  the  surgeon  to  open 
it  transperitoneally  after  thoroughly  protecting  all  surrounding  struc- 
tures by  gauze  packs,  than  for  him  to  attempt  to  cut  directly  into  the 
abscess  ca\4ty.  In  the  latter  method  of  operating  the  surgeon  can 
never  be  entirely  sure  that  his  incision  itself  has  not  trespassed  beyond 
the  limiting  adhesions,  nor  that  his  manipulations  have  not  produced 
leakage  into  the  general  peritoneal  cavity  at  some  other  point  of  the 
abscess's  periphery. 

For  anterior  perigastric  abscess,  median  or  left  hj^pochondriac 
laparotomy  is  to  be  preferred.  Drainage  may  be  provided  for  by  a 
counter  opening  in  the  left  flank,  if  the  abscess  extends  far  toward  the 
spleen. 

For  posterior  perigastric  abscess  (suppuration  in  the  lesser  cavity 
of  the  peritoneum),  laparotomy  should  be  done,  and  the  abscess  opened 
where  most  prominent — whether  it  points  through  the  gastro-hepatic 
or  through  the  gastro-colic  omentum,  or  through  the  transverse  meso- 
colon. Though  recovery  has  followed  anterior  drainage  alone,  it  is 
much  safer  to  make  a  counter  opening  in  the  left  loin,  below  the  last 
rib;  under  such  circumstances  it  is  occasionally  proper  to  close  the 
anterior  incision  without  drainage.  If  the  location  of  the  abscess  in 
the  lesser  peritoneal  cavity  has  been  determined  before  operation,  an 
attempt  should  be  made  to  open  it  through  the  left  ilio-costal  space. 
This  route  has  been  employed  several  times  successfully  by  the  senior 
author,  either  as  the  primary  operation,  or  after  locating  the  abscess  by 
laparotomy. 

For  a  subphrenic  abscess  which  involves  the  subhepatic  space  and 
right  renal  pouch,  laparotomy  combined  with  counter-drainage  in 
the  right  loin  should  be  employed. 

When  the  abscess  does  not  extend  beyond  the  confines  of  the  costal 
margin  on  the  right  it  is  sufficient  to  drain  it  by  the  thoracic  incision. 

The  thoracic  operation  should  never  be  emplo}'ed  if  there  be  diffuse 
peritonitis.  In  the  presence  of  this  additional  complication  there  is  a 
choice  of  two  methods  of  procedure:  i.  If  it  appear  that  the  patient 
will  survive  the  immediate  shock  of  an  operation,  laparotomy  should 
be  done,  the  cause  of  the  peritonitis  abated,  and  drainage  of  the  pelvis 


StlBPHRENIC   ABSCESS  411 

provided  for,  as  well  as  of  the  side  of  the  subphrenic  space  involved. 
2.  If  the  peritonitis  has  advanced  so  far  that  no  operation  can  be 
undertaken  without  great  probability  of  hastening  the  patient's 
death,  the  starvation  treatment  of  Ochsner  should  be  adopted;  but 
any  localized  collection  of  pus  must  be  opened  as  soon  as  it  is  dis- 
covered— delay  of  even  twelve  hours  may  place  the  patient  beyond  the 
reach  of  surgery.  Whichever  plan  of  treatment  be  adopted,  the  head 
of  the  patient's  bed  should  be  raised  30  degrees  from  the  floor  (Fowler's 
position),  to  aid  the  gravitation  of  septic  fluid  to  the  pelvis.  Water 
should  be  constantly  administered  by  the  bowel. 


PART  II 


CHAPTER  XVI 

SURGICAL  DISEASES  OF  THE  BILIARY  TRACT 

General  Etiological,  Pathological  and  Diagnostic 
Considerations 

The  prime  factor  in  all  non-neoplastic  surgical  diseases  of  the 
biliary  tract  is  some  form  of  micro-organismal  invasion.  The  conse- 
quences of  this  may  be  slight  or  grave,  transient  or  chronic,  accom- 
panied by  very  slight  or  very  decided  structural  changes,  the  formation 
of  concretions,  etc.;  but  invariably,  we  believe,  the  underlying,  exciting 
cause  has  been  infection  of  the  tract  by  bacterial  life.  The  only  excep- 
tion to  this  statement  may  be  found  in  those  rare  instances  where 
surgical  diseases  result  from  the  catarrhal  condition  of  the  bile-passages 
consequent  upon  the  action  of  some  toxic  substance,  such  as  is  seen  in 
acute  phosphorus  poisoning. 

Our  present  knowledge  of  the  bacteriology  of  the  biliary  tract 
is  the  result  of  the  work  of  numerous  investigators.'  It  is  known  that 
when  bacteria  gain  entrance  to  the  biliary  tract  they  may  give  rise  to 
infections  that  result  in  (i)  a  mild  catarrhal  condition  of  the  tract; 
(2)  acute  suppurative  cholangeitis  with  or  without  empyema  of  the  gall- 
bladder; (3)  mild,  or  severe,  gangrenous  cholecystitis;  (4)  gall-stone 
formation,  etc.  It  is  known  that  the  bile  itself  is  a  medium  for  the 
growth  of  many  forms  of  bacteria,  and  that  it  is  not,  as  was  formerly 
believed,  a  bactericidal  agent. 

Bacteriology  of  the  Biliary  Passages. — It  generally  has  been  claimed 
that  normal  bile  in  normal  bile-passages  is  sterile  (Hoppe-Seyler,  1903). 
On  the  other  handLippman  (1904)  demonstrated  bacterial  life  in  appar- 
ently normal  common  ducts  and  in  the  normal  ampulla  of  Vater; 
while  the  researches  of  Bond  (see  page  417),  prove  conclusively  that  it  is 
possible  to  find  bacteria  in  normal  mucous  ducts. 

In  our  own  experience  cultures  from  the  biliary  tract  taken  at  opera- 
tion proved  sterile  in  over  55  per  cent,  of  the  cases  examined.  This  is  to 
be  explained  by  the  fact  that  a  majority  of  operations  are  done  not 

'  Free  use  has  been  made,  in  what  follows,  of  the  Mutter  Lecture  of  the  College  of 
Physicians  of  Philadelphia  (1905),  by  Dr.  A.  O.  J.  Kelly,  late  Pathologist  to  the  German 
(now  Lankenau)  Hospital. 

4IS 


4l6  SURGICAL   DISEASES    OF    THE    BILIARY    TRACT 

during  the  acute  stage  of  bacterial  invasion,  but  for  the  remote  results 
of  the  infection  (gall-stones) :  in  the  interval  the  biliary  tract  has 
cleared  itself  of  the  bacteria,  though  the  latter  may  in  some  cases  still 
be  recovered  by  culture  from  the  interior  of  the  calculi  even  when  the 
bile  itself  is  sterile. 

The  bacterium  most  frequently  found  in  the  bihary  tract  is  the 
Bacillus  coli  communis,  which  was  found  in  68  per  cent,  of  our  non- 
sterile  cases;  it  was  followed  in  the  order  of  frequency  by  the  Bacillus 
typhosus  (over  15  per  cent.). 

Among  other  bacteria  that  have  been  found  in  bile  may  be  men- 
tioned Staphylococcus.  Streptococcus,  B.  subtilis,  and  numerous  others. 

Avenues  of  Infection. — Bacteria  gain  entrance  to  the  biliary  tract, 
in  most  instances,  through  the  portal  circulation,  or  through  the  general 
circulation.  Invasion  also  takes  place  through  the  duodenal  opening 
of  the  common  bile-duct,  through  the  lymphatic  circulation,  and  possibly 
through  the  walls  of  the  biliary  tract.  Of  these  various  avenues  of 
entrance  the  portal  circulation  is  the' most  frequently  traversed,  al- 
though many  investigators  have  claimed  that  the  ductal  opening  in  the 
duodenum  is  the  chief  gateway  of  entrance.  It  must  be  remembered 
that  the  duodenum,  in  a  normal  condition  and  especially  when  free  from 
food,  is  almost  free  of  germ  life.  Kelly  pointed  out  two  other  important 
factors  that  must  be  considered  in  connection  with  the  entrance  of 
germs  through  the  ductal  opening:  one  is  the  sphincteric  action  of  the 
ampulla  of  Vater,  which  Archibald  (1912)  found  exerted  a  force  equiva- 
lent to  about  600  mm.  of  water  pressure  within  the  duct;'  the  other  is  the 
peculiar  flushing  of  the  duct  and  its  opening  by  the  intermittent  gushing 
of  bile  into  the  duodenum.  Were  there  a  constant,  free  opening  of  the 
ampulla,  with  a  slow  steady  flow  of  bile  through  the  opening,  this  en- 
trance would  be  a  more  common  avenue  of  infection  than  it  is.  During 
the  presence  of  food  in  this  portion  of  the  intestine,  which  is  almost 
the  only  time  germs  are  present  in  the  normal  duodenum,  there  is  an 
intermittent  expulsion  of  bile  (see  p.  38)  which  naturally  clears  the 
opening  and  the  first  part  of  the  duodenum  of  all  bacteria  that  may 
become  lodged  there. 

The  comparative  freedom  of  the  pancreas  from  infectious  diseases 
has  been  advanced  as  a  strong  argument  against  invasion  taking  place 
through  the  ampulla  of  \'ater.  But  even  if  the  bacteria  make  no 
selection  between  the  pancreatic  and  the  common  bile-ducts  when 
they  reach  the  crossroads  where  these  two  channels  join,  those  entering 
the  pancreatic  duct  are  confronted  bj-  much  greater  obstacles  to  over- 
'  Oddi  (1888)  found  it  equal  to  675  mm.  of  water  pressure. 


AVENUES    OF    INFECTION  417 

come  than  are  their  fellows  who  enter  the  bile  channel.  Many  claim 
that  the  pancreatic  juice  is  antagonistic  to  germ  life,  while  the  bile, 
especially  when  stagnant,  stimulates  instead  of  hinders  the  growth  of 
many  forms  of  bacteria.  There  is  no  such  pool  of  stagnant  pancreatic 
juice  as  there  is  of  bile  in  the  gall-bladder,  and  hence  no  suitable  lodging- 
place  where  bacteria  may  thrive  and  multiply. 

Bacteria  have,  however,  been  found  in  the  normal  diverticulum 
and  in  the  lower  end  of  the  normal  common  duct.  It  is  of  course 
possible  that  such  bacteria  may  have  descended  with  the  bile  from  the 
liver,  which  is  constantly  inundated  by  bacteria  through  the  portal 
circulation.  But  the  experimental  work  of  Bond  (1905),  showed  that  it 
is  possible  for  micro-organisms  to  travel  against  the  natural  currents 
in  mucous  ducts:  He  was  able  to  recover  through  a  fistula  into  the  gall- 
bladder granules  of  indigo  blue  which  had  been  administered  by  mouth. 
His  experiments  seem  to  prove  conclusively  that  it  is  perfectly  possible 
for  bacteria  to  enter  the  common  duct  from  the  duodenum  and  trav- 
erse its  length.  This  may  be  accomplished  not  only  by  the  motile 
bacteria,  such  as  the  colon,  typhoid,  and  paratyphoid  bacilli,  but  also 
by  the  non-motile  staphylococci  and  streptococci. 

The  usual  pathway  of  entrance  in  cases  of  infection  of  the  biliary 
tract  is  through  the  portal  circulation.  Adami  has  shown  that  under 
normal  conditions  bacteria  may  be  found  in  the  deeper  layers  of  the 
intestine,  in  the  portal  circulation,  and  in  the  liver.  He  advances 
the  theory  that  the  leukocytes  carry  the  bacteria  to  the  lymphatic 
radicles  and  also  to  the  radicles  of  the  portal  vein.^  They  may  also 
be  taken  up  by  the  thoracic  duct  and  emptied  into  the  general  circula- 
tion. The  natural  resistive  and  bactericidal  powers  of  the  liver  cells 
are  sufficient  to  overcome  and  destroy  most  of  the  germs  arriving 
through  the  portal  circulation.  If  there  should  be  a  weakened  condi- 
tion of  the  hepatic  cells,  however,  either  through  disease  or  overwork, 
many  of  the  bacteria  will  escape  destruction  and  be  excreted  with  the 
bile.  The  researches  of  Lartigau  (1906)  definitely  settled  the  fact  that 
infection  of  the  biliary  tract  may  be  a  descending  one  from  the  liver. 
Having  tied  the  common  duct  in  animals,  Lartigau  fed  them  bacteria, 
especially  the  Bacillus  pyocyaneus,  and  was  able  to  recover  this  germ 
from  the  gall-bladder  in  almost  50  per  cent,  of  the  animals  so  treated. 
In  many  instances  the  Bacillus  pyocyaneus  was  recovered  in  pure 
cultures;  in  other  instances  the  colon  bacillus  was  associated  with  it. 

Infection    of    the    biliary    tract    through    the   systemic   circulation 

'  It  is  in  this  way  that  appendicitis,  typhoid,  jcver  and  other  infections  in  the  abdomen 
may  act  as  a  predisposing  factor  for  infections  of  the  biHary  tract. 
27 


4l8  SURGICAL   DISEASES    OF    THE   BILIARY    TRACT 

is   possible    and,    in    man}-    instances,    probable.     The    advancement 
in  the  study  of  the  blood  which  has  made  it  possible  to  determine 
the  presence  of  bacteria  in  the  general  circulation  in  certain  infectious 
diseases,  such  as  t}TDhoid  fever,  has  majle  the  systemic  circulation 
seem  much  more  important  as  a  pathway  of  entrance  for  bacteria  to 
the  biliary  tract.     The  work  of  Dorr  (1905)  proved  that  bacteria  in- 
jected into  the  circulation  of  a  rabbit,  can  be  recovered  from  the 
gall-bladder  in  a  few  hours.     As  pointed  out  by  Kelly  the  infections 
of  the  bihary^tract  so  often  found  as  complications  of  systemic  infec- 
tions also  show  the  possibility  and  probabilit}'  of  infection  through  the 
blood.     It  cannot  be  stated  definitely,  however,  whether  the  infection, 
in  these  cases,  takes  place  through  the  hepatic  and  cystic  arteries, 
through  the  portal  vein,  or  through  the  common  duct  from  the  intesti- 
nal canal.     The  presence  of  tj'phoid  bacilli,  unassociated  with  other 
bacteria,  in  the  gall-bladder  in  cases  of  enteric  fever  naturally  strength- 
ens the  belief  that  in  some  instances  at  least  the  s}'stemic  circulation 
conveys  the  germ  to  the  biHary  tract.     This  behef  is  confirmed  by 
the  experiments  and  findings  of  Joseph  Koch  (see  page  428),  as  well  as 
those  of  Wrzosek  and  of  Else  (1910)  and  by  the  more  recent  investiga- 
tions of  Rosenow  (1914)  who  claims  that  bacteria  exert  a  selective 
action  in  choosing  their  place  of  lodgment,  certain  strains  being  specific 
for  the  gall-bladder,  others  for  the  pylorus,  the  appendLx  or  other 
structure. 

In  exceptional  cases  infection  of  the  biliary  tract  may  take  place 
through  the  lymphatic  system,  as  was  probably  the  case  in  an  instance 
reported  by  Miiller  (1905).  Bishop  (1907),  also,  claimed  that  infection 
may  take  place  through  this  channel,  although  its  occurrence  is 
very  rare. 

Infection  through  the  walls  of  the  biliary  tract,  and  especially 
through  the  walls  of  the  gall-bladder,  may  occur  by  contiguity.  It 
is  questionable,  however,  whether  the  infection  tra\'els  from  without 
inward  in  those  cases  where  the  gall-bladder  is  surrounded  by  a  mass 
of  adhesions;  it  is  much  more  likely  that  they  are  relics  of  a  former 
inflammatory  condition  which  probably  had  its  origin  within  the  bile 
passages.  Under  such  circumstances  any  new  inflammatory  processes 
are  more  hkely  to  be  a  rehghting  of  the  old  infection  rather  than  a  new 
one. 

Pathogenesis. — After  the  micro-organisms  have  entered  the  biliary 
tract  the  consequences  of  their  activity  Mill  vary  with  the  virulence 
of  tlie  invading  bacteria,  the  presence  or  absence  of  calcuU,  the  resist- 
ance offered  by  the  structures  affected,  and  the  anatomical  peculiarities 


GALL-STONE   FORMATION  419 

of  the  portion  of  the  tract  involved.  These  changes  may  vary  from  a 
very  rnild,  quickly  subsiding  acute  infection,  to  the  most  violent,  ful- 
minating, gangrenous  process;  from  a  mild,  almost  symptomless 
catarrh  to  a  chronic  inflammation  of  the  biliary  tract  which  may  last  for 
years,  with  acute  exacerbations  causing  greater  structural  changes 
with  each  attack.  Or  the  tract,  and  especially  the  gall-bladder,  may 
be  utihzed  as  a  store-house  for  masses  of  bacteria,  as  frequently  dem- 
onstrated in  the  cases  of  "chronic  typhoid  carriers"  (see  page  432). 

In  many  instances  the  only  changes  that  can  be  noted  are  a  slight 
swelling  of  the  mucous  membrane  with  pdssibly  some  sHght  exfolia- 
tion of  the  epithelium.  Such  patients  usually  rid  themselves  of 
the  infection  through  their  natural  resistance  and  by  an  increase  in 
the  flow  of  bile  which  washes  the  germs  from  the  tract,  tlius  allowing 
the  affected  area  to  heal  with  only  trifling  change  of  structure.  With 
infection  of  greater  viurlence,  or  where  lessened  resistance  exists,  an 
acute  inflammation  of  the  ducts  or  gall-bladder  or  both,  with  or  without 
pus  formation,  will  be  found. 

The  presence  of  inflammation  in  the  ducts  or  gall-bladder  will 
cause  the  mucous  membrane  lining  the  cystic  duct  to  become  swollen 
with  consequent  narrowing  of  its  lumen  and  damming  of  bile  behind 
the  obstruction.  The  partial  or  complete  stasis  of  bile  thus  produced 
provides  an  opportunity  for  germs  to  exert  their  full  power,  the  result 
being  determined  by  the  vindence  of  the  micro-organisms  present, 
and  the  abiHty  of  the  gall-bladder  and  ducts  to  resist  and  overcome  the 
infection. 

Gall-stonk  Formation 

Historical. — Many  and  various  theories  have  been  advanced  at 
different  times  to  account  for  the  formation  of  gall-stones.  A 
more  exact  knowledge  of  the  anatomy  of  the  biliary  tract,  with  a 
better  understanding  of  the  physiological  action  of  the  liver  and  the 
physiology  and  chemistry  of  the  bile,  enhanced  as  these  have  been  by 
the  pathological  findings  at  the  operating  table,  have  explained  the 
most  important  parts  of  the  subject.  The  work  of  Naunyn  settled  the 
question  definitely  in  the  opinion  of  his  followers.  The  researches  of 
Kramer  (1907),  of  Bacmeister  (1908),  and  of  Bishop  (1907),  however, 
threw  doubt  on  some  of  Naunyn's  findings.  A  few  questions  concern- 
ing gall-stone  formation  remain  unanswered,  although  they  are  not  of 
great  importance. 

Originally,  gall-stones  were  supposed  to  be  formed  from  coagu- 
lated bile,  the  coagulation  being  caused  by  a  rise  in  the  temperature  of 


420  SURGICAL   DISEASES    OF    THE   BILIARY    TRACT 

'the  liver.'  Paracelsus  believed  that  gastro-intestinal  disturbances 
caused  an  acid  condition  of  the  blood,  the  acids  which  were  formed 
acting  upon  the  bile  with  consequent  precipitation  and  formation  of 
concretions.  Later  as  a  better  knowledge  of  the  normal  constituents 
of  bile  was  obtained,  it  was  thought  that  a  super-abundance  of  any 
of  its  various  elements  might  exist,  with  consequent  stone  formation. 
Meckel  called  attention  to  a  chronic  catarrhal  condition  of  the  mucous 
membrane  of  the  bile-tract  and  especially  of  the  gall-bladder,  and  ad- 
vanced the  theory  that  a  "stone-forming  catarrh"  might  be  the  basis 
of  the  lithiasis.  Flint  suggested  that  excessive  brain  work  caused  a 
condition  of  cholesteremia ;  this  gave  rise  to  the  theory  that  gall-stones 
were  formed  as  soon  as  an  excessive  amount  of  cholesterin  was  present 
in  the  blood.  Hein  thought  that  plugs  of  mucus,  the  product  of  a 
diseased  condition  of  the  mucous  membrane,  acted  as  nuclei  around 
which  the  stones  were  formed.  He  also  claimed  that  changes  taking 
place  in  the  bile  within  the  bile-tract  might  cause  the  formation  of 
stones — small,  minute,  bile-pigment  stones  first  being  formed  in  the 
ducts;  and  later,  after  they  had  reached  the  gall-bladder,  acting  as 
nuclei  for  larger  stones.  The  supposition  that  the  epithelial  cells  of 
the  gall-bladder  were  important  factors  in  gall  stone  formation  was 
suggested  by  Seifert.  Naunyn  (1892)  advanced  the  idea  that  most 
stones  were  formed  within  the  gall-bladder  as  a  result  of  a  catarrhal 
condition  of  the  mucous  membrane  consequent  upon  bacterial  invasion, 
desquamation  of  epithelial  cells,  and  deposition  from  these  cells  of 
larger  quantities  of  cholesterin  than  the<bile  could  hold  in  solution.  He 
also  claimed  that  the  calcium  bile-salts  acted  as  a  cement  substance, 
through  the  action  of  which  accretions  were  constantly  added  to  the 
original  nucleus  or  stone.  Naunyn  also  thought  that  the  bile-pigment 
stones  were  formed  in  the  ducts  through  oxidation  of  bile,  this  being 
brought  about  by  the  action  of  bacteria.  Xaunyn's  belief  is  generally 
accepted  to-day,  although  later  investigators  differ  with  him  as  to  the 
origin  of  the  excess  of  cholesterin. 

Pathogenesis. — The  actual  formation  of  gall-stones  is  caused  by 
an  increase  of  the  cholesterin  constituent  of  the  bile,  a  deposition  of 
calcium  bile-salts,  especially  bilirubin-calcium,  in  the  presence  of  a 
stasis  or  sluggislmess  infloxv  of  bile.  The  increase  in  cholesterin  and  the 
deposition  of  the  calcium  salts  are  due  to  the  action  of  bacteria.  This 
was  shown  by  the  experiments  of  Gerard  (1905)  and  of  Bacmeister 
(1908).     Neither  of  these  observers  was  able  to  produce  concretions  in 

'  Historical  references  are  given  in  the  monograph  of  Exner  and  Hejrrovsky  (.\rchiv. 
f.  klin.  chir.,  igo8,  Ixx.wi,  609). 


GALL-STONE    FORMATION  421 

sterile  bile  contained  in  a  test-tube,  but  when  colon  bacilli  were  present 
deposition  of  salts  readily  ocurred.  The  interference  with  the  natural 
flow  of  bile  also  may  be  due  to  the  action  of  bacteria  in  creating  a  catar- 
rhal inflammation  of  the  mucous  membrane  of  the  gall-bladder  and 
ducts;  or  it  may  be  consequent  upon  any  of  those  predisposing  causes 
of  cholelithiasis  (seepage476)  which  have  a  tendency  to  cause  stagnation 
of  bile.  It  is  necessary  for  the  inflammatory  changes  caused  by  the 
bacteria  to  be  of  a  very  mild  character;  the  bacteria  themselves  must 
be  almost  non- virulent.  A  virulent  inflammation  of  the  gall-bladder  or 
bile-tracts  will  cause  rapid  changes  in  the  structures  involved,  acute 
cholecystitis  with  its  train  of  complications  and  sequels  (see  page  449) , 
a  cholangeitis  of  purulent  character,  etc.,  rather  than  the  mild,  almost 
symptomless  inflammation  that  is  necessary  for  gall-stone  formation. 
The  source  of  the  increased  amount  of  chohsterin  is  a  question 
that  has  not  been  definitely  settled.  Naunyn  (1905)  attributed  it 
to  the  cells  of  the  mucous  membrane  Hning  the  biliary  tract  which 
are  exfoliated  in  excessive  numbers  as  a  consequence  of  a  very  mild, 
catarrhal  inflammation.  These  cells  contain  droplets  of  myelin, 
of  fluid  cholesterin.  Kramer  (1907)  on  the  other  hand,  derived 
results  from  test-tube  experiments  which  make  it  very  probable 
that  the  cholesterin  may  be  deposited  from  the  bile  itself.  He  was 
able  to  obtain  a  precipitate  from  a  culture  medium  (consisting  of 
equal  parts  of  bouillon  and  bile)  which  had  been  inoculated  either 
with  the  colon  bacillus  or  the  typhoid  bacillus.  The  precipitate 
increased  with  the  age  of  the  culture.  Microscopically  the  precipitate 
consisted  of  biliary  coloring  matter,  cholesterin.  magnesium  phosphate, 
calcium  phosphate,  calcium  carbonate,  and  baciUi.  Kramer  concluded 
from  these  experiments  that  "gall-stone  formation  is  due  to  a  chemical 
decomposition  of  bile,  the  direct  result  of  the  growth  of  micro-organisms 
therein."  Bacmeister  also  differs  from  Naunyn  regarding  the  source  of 
cholesterin,  and  from  Kramer  as  to  the  direct  cause  of  its  deposition  from 
bile.  He  claims  that  there  is  a  more  or  less  constant  autolysis  of  the  bile, 
with  the  deposition  of  cholesterin  from  it;  that  this  autolysis  is  much 
more  marked  when  the  bile  is  contaminated  by  epithelial  cells  or  bacteria. 
Experimentally,  he  was  able  to  demonstrate  the  separation  of  choles- 
terin crystals  from  sterile  bile,  and  even  from  filtered  bile,  although  sepa- 
ration in  the  latter  instance  was  much  slower  than  in  unfiltered  bile. 
In  the  presence  of  the  Bacillus  pyocyaneus,  the  Bacillus  proteus, 
the  Bacillus  typhosus,  or  the  Bacillus  coli  communis  he  was  able  to 
demonstrate  a  very  marked  precipitation  of  cholesterin.  Bishop 
holds  that  an  inflammatorv  condition  of  the  mucous  membrane  of  the 


42  2  SURGICAL   DISEASES    OF    THE   BILIARY    TRACT 

biliary  tract  is  the  initial  step  in  gall-stone  formation,  the  change  in  the 
membrane  being  the  direct  result  of  bacterial  invasion,  the  bacteria 
penetrating  the  walls  of  the  tract  with  the  resultant  mild  inflammation. 
The  result  of  this  inflammation  is  an  outpouring  of  cholesterin  in  larger 
quantities  than  can  be  dissolved  by  the  bile.  This  view  is  in  keeping 
with  that  of  Naunyn  and  was  well  summarized  by  Kelly  (1908)  who 
said  "the  increased  cholesterin,  then,  is  derived  not  from  the  bile,"  "it 
results  from  catarrhal  disintegration  of  the  mucous  cells  lining  the 
wall  of  the  gall-bladder"  (the  seat  of  the  formation  of  most  gall- 
stones). 

All  observers  are  agreed  that  the  mild  inflammation  of  the  mucous 
membrane  causes  an  increased  secretion  of  mucus,  an  albuminous 
substance  which  causes  precipitation  of  the  calcium  bile-salts,  especially 
the  bihrubin-calcium.  There  is  also  an  increase  in  the  exfoliation  of 
epithelial  cells.  Naunyn  claims  that  the  mucus,  cholesterin  and  epithe- 
lial cells  act  as  a  nucleus  for  the  beginning  stone,  being  held  together 
by  the  bilirubin-calcium  which  acts  as  a  cement  substance.  Bacmeis- 
ter,  on  the  contrary,  claims  that  the  first  stone  formed  is  composed,  al- 
most invariably,  of  pure  cholesterin;  that  the  presence  of  this  stone 
creates  conditions  very  favorable  for  bacterial  infection  with  inflam- 
matory changes  in  the  walls  of  the  gall-bladder,  and  that  these  changes 
cause  marked  increase  in  the  secretion  of  mucus.  This  mucus  is 
very  rich  in  calcium  salts  which  furnish  material  for  the  formation 
of  new  stones,  as  well  as  for  the  deposition  of  additional  layers  on 
the  surface  of  the  stone  already  formed.  Basing  their  views  largely 
on  the  experimental  work  of  Bacmeister,  Aschoff  and  Bacmeister,  in 
their  monograph  on  Cholelithiasis  (1909)  claimed  that  with  very  few 
exceptions  the  first  calculus — a  cholesterin  stone  with  radially  disposed 
crystals — is  formed  without  any  bacterial  infection  of  the  biliary 
tract,  merely  by  chemical  changes  in  the  stagnant  bile  of  a  gall-bladder 
more  or  less  obstructed  by  mechanical  means,  such  as  kinks  of  the  cystic 
duct,  a  viscid  state  of  the  bile,  etc. 

The  sluggisJiness  in  the  flow  of  bile,  or  even  actual  stasis  is  favored 
by  two  principal  factors:  (i)  changes  in  the  bile  itself;  (2)  changes  in 
the  bile-ducts.  The  composition  of  the  bile  is  altered  by  the  chemical 
changes  already  alluded  to,  induced  by  bacteria;  it  becomes  thicker, 
more  viscid,  less  fluid.  The  bile-ducts  become  narrowed  and  eventually 
obstructed  by  inflammatory  edema,  b}-  kinks  due  to  the  drag  of  an 
inflamed  gall-bladder,  by  impaction  of  calculi,  of  by  pressure  of  surround- 
ing adhesions,  tumors,  etc.  Waugh  (1920)  has  made  a  strong  plea  for 
the  recognition  of  a  congenitally  mobile  ascending  colon  as  a  factor  in 


PHYSICAL   CHARACTERS    OP    GALL-STONES  423 

the  production  of  the  stagnant  gall-bladder.  In  ten  patients  in  whom 
these  lesions  were  associated  he  noted  the  presence  of  a  well  developed 
fold  of  peritoneum  running  from  the  fundus  of  the  gall-bladder  to  the 
hepatic  flexure  of  the  colon  (the  so-called  cholecysto-colic  ligament), 
which  he  regards  as  the  medium  of  traction. 

Moreover,  when  calculi  have  once  formed,  the  impaction  of  a  calculus, 
and  the  damming  up  behind  it  even  temporarily,  of  altered  bile,  must 
be  recognized  as  favoring  the  formation  of  other  calcuH. 

Finally,  a  word  should  be  said  about  calculous  formation  around 
foreign  bodies  as  a  nucleus  (page  479).  Such  cases  have  been  observed 
by  many  surgeons,  including  Homans  (1897)  and  Kehr  (1901),  each 
of  whom  reported  instances  of  stones  forming  around  silk  ligatures 
employed  at  operation.  Hence  the  rule,  in  biliary  surgery,  to  employ 
only  sutures  of  absorbable  material.  It  has  been  shown  experimentally 
that  sterile  foreign  bodies  introduced  into  the  healthy  gall-bladders  of 
dogs  do  not  lead  to  the  formation  of  gall-stones  (Meyer) ;  but  that  in 
the  presence  of  attenuated  infection  concretions  may  readily  be  produced 
(Mignot). 

The  rapidity  of  gall-stone  formation  is  much  greater  than  commonly 
supposed.  Naunyn,  in  1905,  stated  his  belief  that  they  might  be 
formed  within  a  few  hours.  Aschofl  and  Bacmeister  claim,  however, 
that  the  radial  cholesterin  stone  is  of  extremely  slow  formation,  many 
years  being  required  to  produce  one  of  nut-size. 

Physical  Characters  of  Gall-stones. — The  color  depends  upon  the 
composition  of  the  stone,  varying  from  the  almost  pure  white  or 
yellowish  stone,  which  is  composed  of  cholesterin,  to  the  black  stone 
which  contains  an  abundance  of  bile-coloring  matter.  The  color 
varies  in  all  stones,  even  the  practically  pure  cholesterin  stone  showing 
dark  patches  of  coloring  matter  between  the  crystals,  and  no  stone 
being  uniform  throughout.  The  surface  is  generally  darker  than  the 
inside  of  the  stone;  while  the  nucleus  is,  as  a  rule,  lighter  in  color 
than  the  surrounding  parts. 

The  hardness  of  the  stone  varies  in  proportion  to  the  amount 
of  calcium  salts  present.  The  cholesterin  stones,  while  more  or  less 
firm  and  hard  to  the  touch,  are  brittle  and  can  readily  be  broken 
between  the  thumb  and  fingers.  Stones  recently  formed  generally 
are  soft. 

The  shape  of  the  concretions  generally  varies  with  the  number 
present.  Single  stones  are  more  or  less  rounded  in  shape,  and  of 
course,  never  faceted.  When  a  number  of  stones  are  present,  they 
are  usually  faceted,  being  pressed  into  this  shape  by  the  contractions 


424 


SURGICAL    DISEASES    OF    THE    BILIARY    TRACT 


of  the  gall-bladder  while  they  are  still  soft  (Fig.  132).  As  a  rule, 
a  large  mass  of  stones,  unless  greatly  disturbed,  will  take  the  form 
of  the  gall-bladder,  the  portions  of  the  stones  on  the  outside  of  the 
mass  and  in  contact  with  the  walls  of  the  gall-bladder  being  usually 
rough  and  more  or  less  rounded,  while  the  portion  of  each  stone  in 
contact  with  other  stones  will  be  pressed  fiat.  The  stones  in  the 
center  of  the  mass  are  almost  universally  faceted.  Xaunyn  asserts 
that  this  faceting  is  due  entirely  to  pressure,  and  not  to  a  grinding 
motion  among  the  stones;  but  it  is  difficult  to  see  how  some  of  the 
facets  become  so  highly  polished  unless  it  is  by  attrition. 

The  "mulberry"  stones  generally  are  composed  of  a  great  number 
of  small  concretions  which  have  coalesced,  finally  being  covered  with 
a  new  layer  which  gives  the  stones  their  appearance  of  uniformity. 


Fig.  132- — Mass  of  Gall-stones  Conglomerated  and  Pressed  into  the  Shape  of  the  Gall- 
bladder.    From  a  Patient  in  the  Lankenau  (Formerly  German)  Hospital. 


In  weight  and  size  the  largest  stone  known  is  that  reported  by 
Richter  in  1793:  this  calculus,  removed  from  the  common  duct  at 
autopsy,  weighed  three  ounces  and  five  drachms  (116  grams).  W. 
Bartlett,  of  St.  Louis,  has  successfully  removed  from  the  common 
duct  a  stone  measuring  4  by  i^?  inches,  and  weighing  two  ounces 
and  a  half  (80  grams).  For  other  noteworthy  instances  of  unusually 
large  stones,   the  reader  may  consult  Packard's  monograph   (1903). 

The  size  of  the  stones  usually  varies  inversely  with  their  number, 
which  may  range  from  a  single  stone  to  many  thousands.  There 
seems  to  have  been  nothing  discovered  which  will  definitely  account 
for  their  variation  in  number.  The  number  formed  may  depend  upon 
the  amount  of  calcium  salts  present.  These  act  as  a  cement  sub- 
stance; and  when  they  are  present  in  abundance,  there  may  be  a 
coalescence  of  a  greater  number  of  the  particles  of  mucus,  cholesterin 
and  epithelial  cells  which  generally  form  the  nuclei,  and  a  correspond- 
ingly smaller  number  of  fully  developed  calculi;  while  with  a  deficiency 


CLASSIFICATION    OF    GALL-STONES  425 

in  the  calcium  salts,  the  particles  may  remain  distinct  and  separate, 
thus  presenting  a  much  greater  number  of  nuclei.  The  largest  number 
of  calculi  found  in  any  one  case,  according  to  Rolleston  (1905),  was 
recorded  by  Otto,  who  counted  7802. 

It  is  probable  that  the  stones  usually  originate  in  the  gall-bladder, 
and  that  they  are  all  formed  nearly  simultaneously ;  but  when  a  solitary 
stone  becomes  impacted  in  one  of  the  ducts,  we  see  no  good  reason  for 
disputing  the  possibility  of  the  subsequent  formation  of  other  stones 
in  the  stagnated  bile,  provided  the  factors  necessary  for  gall-stone 
formation  are  still  present. 

According  to  Rolleston,  Mignot  concluded  from  experimental 
researches  that  additional  calculi  might  be  formed  in  recurrent  attacks 
of  cholecystitis.  Reference  has  already  been  made  (p.  422)  to  the 
teaching  of  Aschofl  and  Bacmeister,  that  the  "radial  cholesterin 
stone"  is  always  formed  first,  without  bacterial  infection,  and  that 
subsequent  bacterial  invasion  causes  the  deposition  of  calcium  bile- 
stones.  Naunyn  drew  attention  to  the  fact  that  where  numerous 
calculi  are  found,  they  are  almost  always  alike  in  general  appearance, 
and  came  to  the  conclusion  that  gall-stones  in  a  single  individual 
always  were  formed  from  a  single  infection  of  the  gall-bladder,  and 
that  recurrences  of  such  infection  in  that  particular  individual  were 
very  rare.  Kehr  (1901)  thought  that  the  vast  majority  of  stones 
are  formed  in  the  gall-bladder  and  that  those  instances  of  stone  forma- 
tion taking  place  within  the  ducts  are  "extremely  rare." 

Gall-stones  may  be  classified  in  many  ways.  Most  authors 
follow  Naunyn,  who  described  six  varieties: 

1.  Pure  Cholcstcnn  Stones. — These  are  more  or  less  uncommon, 
although  this  variety  is  the  one  that  Aschoff  and  Bacmeister  claim 
precedes  the  formation  of  all  other  varieties.  As  a  rule  they  are  of 
large  size.  They  generally  present  the  following  characteristics: 
they  are  oval,  at  times  being  spheroid;  hard,  but  brittle,  so  that  they 
may  be  crushed  between  the  thumb  and  finger;  the  surface  may  be 
either  smooth  or  nodular;  in  color  they  vary  from  pure  white  or  yellow- 
ish to  brownish-black  on  the  surface,  with  a  white  and  generally  crystal- 
line interior.  They  are  not  stratified,  the  cholesterin  crystals  being 
radially  arranged  around  a  comparatively  soft  center  of  amorphous 
material  (Figs.  133,  134).  Rarely  an  amber  like  calculus  may  be 
found — amber  yellow,  translucent,  irregular  on  the  surface,  and  with 
the  consistency  of  rosin. 

2.  A  Laminated  Variety  of  Clinlesterin  Stones. — These  are  composed 
of  cholesterin,  bilirubin-calcium,  biliverdin-calcium,  and  calcium  car- 


426 


SURGICAL   DISEASES    OF   THE   BILIARY   TRACT 


bonate.  These  calculi  usually  contain  about  90  per  cent,  of  cholesterin. 
They  may  occur  singly  or  in  varying  numbers,  when  they  are  at  times 
faceted.  A  section  reveals  laminations,  layers  of  almost  pure  white 
cholesterin  alternating  with  yellowish,  brown,  red,  or  green  layers. 
The  body  of  the  stone  generally  is  non-crystalline,  while  the  center  or 


Fig.  133. — Radial  Cholesterin  Gall-stono;  Spontaneous  Fracture  in  Gall-bladder. 
Female,  Aged  50  Years,  with  Empyema  of  Gall-bladder.  Recovery.  Scale  in  Inches.  (See 
Fig.  134.)  From  a  Patient  under  the  Junior  Author's  Care  in  the  Episcopal  Hospital. 
(Ashhtirsi's  Surgery.) 

nucleus  may  be  crystalline  or  may  be  hollow  when  the  calculus  has 
become  dry.  These  calculi,  according  to  Aschoff  and  Bacmeister, 
usually  are  formed  by  accretions  around  the  primary  "radial  cho- 
lesterin stone  "  as  a  nucleus. 

3.  T/ie  Common  Gall-stones,  or  Mixed  Cholesterin  Calculi. — They  vary 
greatly  in  number  and  in  size  and  usually  are  faceted  (Plates  V  and  VI). 
The  surface  varies  in  color  from  yellow,  the  usual  color,  to  a  brown  or 
at  times,  a  white  color.  Their  consistency  depends  a  great  deal  upon 
the  time  of  their  examination.  When  freshly  removed  from  the  gall- 
bladder they  may  be  rather  soft  with  a 
"soapy"  feel;  after  they  have  dried  out 
they  become  harder.  The  center  of 
this  variety  is  also,  at  times,  a  cavity; 
it  usually  is  softer  than  the  outside. 

4.  Mixed  bilirnbin-calcium  stones,  in 
which  there  is  a  preponderance  of  the 
bile-pigment  salt,  with  about  25  per 
cent,  of  cholesterin.  They  are  often  of 
considerable  size.  They  generally  occur 
singly  or  in  groups  of  three  or  four,  in 
which  instances  they  may  be  faceted. 
On  section  they  show  concentric  layers  of 
dark  material  which  is  generally  reddish-brown  in  color.  The  interior 
of  the  stones  as  a  rule  is  rather  soft;  on  drying,  the  stones  usually  con- 
tract with  the  formation  of  fissures. 


Fig.  134. — Cholesterin  Gall-stone, 
with  Polished  Facet  at  Each  End. 
Same  Stone  Shown  in  Pig.  133  after 
Fragments  had  been  Glued  Together. 
(Ashhurst's  Surgery.) 


Plate  V 


Specimen   Secured   by   Cholecystectomy,  Showing  Cholelithiasis  with  Patch  of  Gangrene 
and  Threatening  Perforation.     Lankeyian  Hospital. 

Face  p.  426 


TYPHOID   INFECTIONS    OF    THE   BILIARY   TRACT  427 

5.  Pure  bilirubin-calciiim  stones,  which  are  of  two  types:  They  may 
be  small  brownish-black  calculi,  with  irregular  surfaces,  and  showing  a 
tendency  to  adhere  one  to  the  other;  this  type  is  rather  soft  in  consist- 
ency. The  other  type  is  much  larger  and  much  smoother  on  the  sur- 
face, which  usually  exhibits  a  metallic  luster,  while  the  interior  of  the 
stone  is  rather  spongy  in  consistency. 

6.  In  this  class  Naunyn  places  some  rare  forms  including  among 
them  calcareous  stones,  pearly  bodies  which  consist  of  amorphous  or 
partly  crystalline  cholesterin,  casts  of  the  biliary  passages,  etc: 

The  pathology,  symptomatology,  diagnosis,  and  treatment  of,  gall- 
stone disease  will  be  considered  in  a  subsequent  chapter  (see  page  460 ) . 

Typhoid  Infections  of  the  Biliary  Tract 

The  infections  of  the  biliary  tract  by  the  typhoid  and  para-typhoid 
bacilh  are  of  great  importance.  Not  only  because  of  the  surgical 
conditions  that  arise  from  such  infections  is  this  true,  but  also  from  the 
standpoint  of  public  health  and  hygiene.  Many  epidemics  of  enteric 
fever  have  been  traced  directly  to  persons  who  were  suffering  from  a 
more  or  less  remote  typhoid  infection  of  the  gall-bladder  and  bile-ducts. 
The  usual  medical  measures,  such  as  cholagogues,  are  of  no  value  in 
ridding  the  biliary  tract  of  the  Bacillus  typhosus.  Nichols  (191 7), 
however,  on  the  theory  that  increasing  the  alkalinity  of  the  bile  tends 
to  sterilize  it,  treated  two  patients  successfully  by  administering  daily, 
for  about  ten  days,  two  grains  of  sodium  carbonate.  The  efficiency 
of  the  vaccine  treatment  has  not  been  established;  though  Dixon  (1917) 
employed  it  successfully  in  one  patient,  in  the  case  reported  by  Leary 
(1913)  it  was  entirely  useless.  It  has  thus  become  necessary  for  the  sur- 
geon to  devise  ways  and  means  for  accomplishing  the  end  in  view — 
ridding  the  system  of  the  remaining  typhoid  bacilli.  The  treatment  of 
these  patients  is  considered  at  page  433. 

Infections  of  the  gall-bladder  and  bile-tracts  have  been  recognized  as 
complications  of  typhoid  fever  by  almost  every  one  who  has  studied  many 
cases  of  the  latter  affection.  Since  1897,  when  Mason  reviewed  the 
history  of  this  complication  of  typhoid,  numerous  investigators  have 
carefully  studied  the  subject  and,  as  Kelly  says,  have  reached  a  com- 
paratively unanimous  conclusion  "(i)  that  the  typhoid  bacillus  is 
regularly  present  in  the  gall-bladder,  and  commonly  in  pure  culture,  in 
practically  all  cases  of  typhoid  fever — indeed,  it  is  the  one  region  of  the 
body  from  which  a  pure  culture  of  the  organism  is  most  likel}'  to  be 
obtained;  (2)  that  the  typhoid  bacillus  may  persist  in  the  gall-bladder, 


428  SURGICAL   DISEASES    OF    THE   BILIARY    TRACT 

as  well  as  within  gall-stones,  weeks,  months,  even  years  after  the  patient 
has  recovered  from  an  attack  of  typhoid  fever;  (3)  that  cholangitis 
and  cholecystitis  (catarrhal,  suppurative,  and  gangrenous)  are  by  no 
means  infrequent  complications  of  typhoid  fever;  and  (4)  that  a  history 
of  antecedent  typhoid  fever  may  be  obtained  in  many  cholelithic  and 
cholecystic  subjects." 

The  presence  of  the  bacilli  in  the  gall-bladder  is  explained  in  two 
ways.  It  is  the  generalh'  accepted  theory,  as  explained  at  page  41 7, 
that  bacteria  are  constantly  passing  from  the  intestinal  tract  to  the 
liver,  in  the  portal  circulation.  Normally  these  bacteria  are  destroyed 
in  the  liver;  but  if  the  liver  cells  become  overburdened  by  the  work 
thrown  upon  them,  or  are  poisoned  by  the  to.xins  thrown  out  by  the 
bacilU,  their  bactercidal  power  is  lost,  and  live  bacilli  are  then  excreted 
with  the  bile.  That  infection  may  occur  also  by  the  systemic  circulation 
is  suggested  by  the  observations  of  Joseph  Koch,  Wrzosek,  and  Else. 
Koch  discovered  inflammatory  infiltration  in  the  mucous  membrane  in 
a  case  of  beginning  typhoid  cholecystitis,  the  infiltrate  containing  dense 
clumps  of  bacilli  resembling  capillary  emboli.  From  these  foci,  he 
claims,  the  baciUi  pass  through  the  epithelium  into  the  interior  of  the 
gall-bladder.  In  experimental  work  on  rabbits  he  was  able  to  follow 
the  transit  of  the  bacilli  from  the  capillary  emboli  in  the  submucosa 
through  the  walls  of  the  gall-bladder.  In  these  experiments  he  injected 
typhoid  bacilli  into  the  veins  of  rabbits  and  recovered  them  from  the 
gall-bladder  even  in  those  cases  in  which  he  had  previously  tied  the 
cystic  duct. 

Although  the  excretion  (or  secretion)  of  bile  by  the  liver  cells  is 
almost  constant,  its  discharge  into  the  duodenum  varies  with  the  needs 
of  the  digestive  functions.  During  the  periods  of  digestive  quiescence 
the  bile  backs  up  through  the  cystic  duct  into  the  gall-bladder  where  it 
remains  until  needed  in  the  intestinal  tract.  Typhoid  fever  patients  are 
kept  on  an  extremely  low  diet,  large  quantities  of  bile  not  being  required 
for  its  digestion  and  absorption.  In  consequence  of  this  fact,  the  gall- 
bladder naturally  becomes  distended  with  bile,  and  the  latter  becomes 
more  or  less  loaded  with  mucus.  If  the  mucus  causes  a  partial  obstruc- 
tion of  the  cystic  duct,  the  bile  will  become  stagnated,  allowing  rapid 
multiplication  of  any  bacteria  that  may  be  present.  Under  these 
conditions,  with  good  resistance  on  the  part  of  the  patient,  there  will 
result  a  slight  inflammation  in  the  gall-bladder,which  is  overlooked  in 
many  instances  because  the  patient's  sensibilities  are  numbed  by 
the  typhoid  infection  and  he  docs  not  experience  sufficient  pain  to 
attract  the  attention  of  the  physician;  and  the  physician  will  overlook 


TYPHOID   INFECTIONS    OF    THE   BILIARY   TRACT 


429 


it,  unless,  as  Kelly  urges,  "systematic  and  repeated  examinations  of  the 
gall-bladder  region  are  undertaken." 

With  lessened  resistance,  the  bacilli  are  allowed  greater  freedom 
of  action,  and  there  results  a  more  pronounced  cholecystitis,  with 
or  without  ulceration  of  the  mucous  membrane  or  even  of  the  entire 
wall  of  the  gall-bladder,  and,  at  times,  perforation  of  that  viscus. 

In  the  presence  of  pre-existing  cholelithiasis,  infection  of  the  gall- 
bladder during  the  course  of  typhoid  fever  might  be  expected  to  cause 
marked  inflammatory  changes,  due  to  the  fact  that  pathological  lesions 
already  exist  in  that  viscus  as  a  result  of  the  presence  of  the  calculi. 

No  conclusive  statistics  as  to  the  frequency  with  which  the  gall- 
bladder is  involved  in  typhoid  fever  have  been  published.  The  junior 
author  in  analyzing  (1908)  the  reports  of  the  Episcopal  Hospital 
found  that  among  2864  cases  of  typhoid  fever  there  were  but  eighteen 
or  0.62  per  cent,  in  which  infection  of  the  gall-bladder  was  recorded  as 
a  complication.  Thomas  (1907),  in  a  series  of  895  cases  of  typhoid, 
found  cholecystitis  in  twelve  or  1.3  per  cent. 

In  connection  with  two  cases  of  perforation  of  the  gall-bladder 
during  typhoid  fever  treated  by  operation,  the  junior  author  analyzed 
the  reports  of  nineteen  other  operations  on  the  gall-bladder  during 
typhoid  fever.'     The  lesions  found  at  operation  were  as  follows: 


Operations  for  gall-bladder  lesions 
during  typhoid  fever 


Cases      j  Recovered 


Died 


Mortality 
per  cent. 


Cholecystitis  alone 

Cholecystitis  and  empyema  of  the  gall- 
bladder  

Cholecystitis,  empyema,  peritonitis 

Perforation  with  peritonitis 

Perforation  (found  only  at  autopsy) 

Total 


4 

2 

2 

3 

0 

3 

4 

2 

2 

6 

4 

2 

4 

0 

4 

21 

8 

13 

50.00 
100.00 

50.00 

33-3° 
100.00 

61 .90 


Quenu  (1908)  collected  forty-five  operations  for  lesions  of  the  gall- 
bladder during  or  soon  after  an  attack  of  typhoid  fever,  and  Reid  and 
Montgomery  (1920)  have  collected  18  cases  occurring  in  patients  less 
than  15  years  of  age. 

[Thomas  has  analyzed  154  cases  of  typhoidal  cholecystitis  collected 
from  the  literature.  He  reports  that  perforation  of  the  gall-bladder 
occured  in  thirtj^-nine  or  25.3  per  cent.  Eleven  of  these  patients  were 
operated  upon  with  a  mortality  of  54.6  per  cent.  The  remaining 
twenty-eight  died  without  operation.  The  Bacillus  typhosus  was 
'Price  (1916)  collected  nine  further  such  operations,  with  one  death. 


430  SURGICAL   DISEASES    OF    THE   BILIARY    TRACT 

isolated  in  about  50  per  cent,  of  the  cases  subjected  to  operation; 
calculi  were  found  in  three.  In  the  series  reported  by  the  junior 
author  the  typhoid  bacillus  was  recovered  in  pure  culture  from  the 
gall-bladders  of  nine  patients  or  42.8  per  cent.  In  one  case,  the  ty- 
phoid bacillus  was  associated  with  the  colon  bacillus;  in  another  case 
the  paracolon  bacillus  was  found;  in  ten  cases  the  bacteriological 
findings  were  not  recorded. 

S}miptoms  and  Treatment  of  Gall-bladder  Disease  during  Ty- 
phoid fever. — There  are  two  quite  distinct  classes  of  cases :  In  the  first 
there  is  a  more  or  less  gradual  onset  of  abdominal  pain,  fairly  well 
localized  (by  patients  who  are  conscious)  to  the  right  hypochondrium, 
accompanied  by  localized  tenderness,  and  frequently  by  a  palpable 


Fig.  135. — Perforalion  u£  the  Gall-bladder  during  Typhoid  Fever;  Cholecystectomy; 
Recovery.  Natural  Size.  From  a  Patient  under  the  Junior  Author's  Care  in  the  Episcopal 
Hospital. 

mass  easily  recognized  as  the  distended  gall-bladder.  If  operation  is 
undertaken  at  this  stage,  there  is  found  (a)  cholecystitis;  (b)  empyema; 
or  (c)  empyema  and  commencing  suppurative  pericholecystitis.  In  the 
second  class  of  cases  the  symptoms  already  mentioned  have  existed 
for  a  period  varying  from  a  few  hours  to  a  week  or  ten  days,  when 
suddenly  there  is  an  acute  attack  of  abdominal  pain,  accompanied 
by  a  fall  of  temperature  (noted  in  eight  out  of  ten  cases),  and  some- 
times by  sweating;  these  signs  being  gradually  followed,  when  immedi- 
ate operation  is  not  undertaken,  by  a  secondary  rise  of  temperature, 
a  spread  of  the  pain  and  tenderness  over  the  whole  abdomen,  and 
increase  of  distention  as  the  initial  rigidity  disappears. 

When  cholecystitis  is  recognized  as  a  complication  during  an 
attack  of  typhoid  fever,  it  is  not  desirable  to  resort  immediately  to 
operation.  The  condition  should  be  closely  watched,  and  only  when 
it  is  thought  that  empyema  is  present  or  perforation  threatens,  should 
the  gall-bladder  be  drained.  If  perforation  occurs,  no  delay  should  be 
allowed;  in  most  cases  cholecystectomy  is  the  operation  of  choice.  If 
the  cholecystitis  subsides  without  operation,  the  patient  should  be  kept 


TYPHOID   INFECTIONS    OF    THE   BILIARY   TRACT  431 

under  observation,  and  such  dietetic  and  hygienic  treatment  should  be 
instituted  as  is  suitable  in  cases  of  cholehthiasis,  since  the  subequent 
development  of  calculi  is  very  probable. 

Sequels  of  T}rphoid  Infection  of  the  Biliary  Tract. — It  is  almost 
impossible  to  arrive  at  definite  conclusions  in  regard  to  the  secjuels  of 
typhoid  infections  of  the  biliary  tract.  In  a  series  of  521  operations 
for  cholelithiasis  performed  by  the  senior  author  at  the  Lankenau  (for- 
merly German)  Hospital  a  positive  history  of  antecedent  typhoid  was 
obtained  from  127  patients  or  24.3  per  cent.  The  time  elapsing 
between  the  attacks  of  typhoid  and  the  time  of  operation  varied  from 
two  weeks  to  forty-one  years.  It  is  questionable  whether  all  of  these 
cases  should  be  classed  as  sequels  of  typhoid  fever,  and  there  is  no  way 
of  deciding  this  question.  A  decision  based  solely  on  the  bacteriologi- 
cal findings  leads  to  one  conclusion;  but  if  based  on  the  accepted 
pathogenesis  of  gall-bladder  infections  (recollecting  that  the  gall-bladder 
may  rid  itself  of  all  bacteria  after  the  subsidence  of  the  acute  infection) 
a  different  conclusion  may  be  reached.  Among  a  series  of  eighty-one 
patients,  at  the  Lankenau  Hospital,  with  a  history  of  antecedent 
typhoid  infection,  the  contents  of  the  gall-bladder  were  examined  bac- 
teriologically  in  forty-six;  of  these,  thirteen  cases,  or  28.4  per  cent., 
gave  cultures  of  the  bacillus  typhosus.  It  cannot,  however,  be  stated 
positively  that  none  of  the  remaining  sixty-eight  cases  should  be  classed 
as  sequels  of  typhoid  fever;  since  these  might  be  cases  in  which  the  gall- 
bladder had  rid  itself  of  the  Bacillus  typhosus  after  this  infection  had 
caused  structural  changes,  the  deposition  of  concretions,  etc.  In  fifteen 
or  32.6  per  cent,  of  the  forty-six  examinations,  pure  cultures  of  the 
colon  bacillus  were  obtained.  Here  again  it  is  uncertain  whether  these 
cases  should  be  classed  as  sequels  of  the  antecedent  typhoid,  or  as 
cholehthiasis  resulting  from  the  invasion  of  the  gall-bladder  by  the 
colon  bacillus;  but  we  believe  that  the  calculous  formation  in  these 
cases,  with  possibly  a  few  exceptions,  was  a  direct  result  of  the  path- 
ological changes  consequent  upon  the  typhoid  infection.  There  might 
also  be  classed  in  the  same  category  seventeen  (36.9  per  cent.)  of  the 
forty-six  cases  in  which  the  gall-bladder  was  sterile  at  the  time  of 
operation,  and  one  case  in  which  Staphylococcus  aureus  was  found. 

A  general  summary  of  the  thirteen  cases  giving  a  pure  culture  of 
the  Bacillus  typhosus  follows: 

Sex. — All  were  females.  Age. — The  age  varied  from  twenty-three 
to  fifty-six  years,  at  time  of  operation,  the  average  age  of  the  thirteen 
being  40.3  years.  Time  since  convalescence  from  lyphoid:  This  varied 
from    two    weeks    to    forty-one   years,    the   time   being   respectively. 


432  SURGICAL   DISEASES    OF    THE   BILIARY    TRACT 

two  weeks;  one  month;  tiv'e  weeks;  four  months;  five  months; 
nine  months;  three  years;  seven  years;  eight  years;  fourteen  years; 
fifteen  years;  forty-one  years;  one  case  not  stated.  Operations: 
Cholecystectomy  was  pei formed  in  six  cases;  cholecystectomy  with 
choledochostomy,  in  three;  cholecystostomyin  three;  choledochostomy 
in  one.     Results:  All  recovered. 

Thomas  in  his  analysis  of  154  cases,  quoted  above,  which  he  classed 
as  complications  or  sequels  of  typhoid,  found  the  Bacillus  typhosus  in 
50  per  cent.;  but  in  those  patients  in  whom  the  gall-bladder  condition 
arose  during  the  course  of  typhoid  fever,  the  typhoid  bacillus  was 
present  in  the  gall-bladder  in  perhaps  95  per  cent. 

More  definite  findings  will  have  to  be  obtained  before  cases  similar 
to  those  in  the  various  series  mentioned  above  can  be  classed  with 
certainty  as  complications  or  sequels  of  typhoid,  and  not  acute  or 
chronic  diseases  of  the  biliary  tract  in  patients  in  whom  an  antecedent 
attack  of  typhoid  fever  was  but  a  coincidence,  although  we  believe 
that  most  of  these  cases  should  be  placed  in  the  former  category;  cer- 
tainly when  the  typhoid  bacillus  is  found  in  the  gall-bladder  the  pre- 
sumption is  warranted  that  it  has  caused  the  disease. 

Another  very  interesting  condition  has  been  made  evident  by 
bacteriological  examination  made  as  routine  in  cases  of  operation  on 
the  gall-bladder.  This  is  the  fact  that  injection  oj  the  biliary  trad  by 
the  Bacillus  typhosus  may  occur  in  patients  who  have  never  presented 
any  symptoms  of  typhoid  fever,  the  invasion  giving  rise  to  a  primary 
typhoid  cholecystitis.  Quenu  (1908)  pointed  out  that  tjphoid  fever 
is  not  primarily  an  intestinal  disease  (wherefore  the  term  enteric  fever 
is  to  be  avoided),  but  a  primary  septicemia;  and  that  the  liver  is  the 
primary  agent  for  the  ehmination  of  the  Bacillus  typhosus,  which  is 
brought  to  it  by  the  blood.  In  this  manner  the  bile  becomes  infected; 
and  he  asserts  that  many  jaundices — hepatic,  epidemic,  or  simple 
febrile  in  character — are  nothing  less  than  primary  infections  of  the 
bile  passages  by  the  bacillus  tj'phosus. 

Typhoid  Carriers. — From  the  standpoint  of  public  health,  the 
most  important  cases  of  typhoid  infections  of  the  biliary  tract  are 
found  in  those  individuals  who  are  chronic  "typhoid  carriers."  In 
this  condition  the  patient  recovers  from  the  attack  of  typhoid  but  does 
does  not  rid  himself  of  the  typhoid  bacilli,  which  remain,  usually 
in  the  gall-bladder,  being  discharged  from  that  viscus  into  the  intestinal 
tract  and  excreted  with  the  feces.  Some  of  these  persons  give  no  his- 
tory of  an  illness  resembling  typhoid  fever.  Repeated  instances  of 
epidemics  arising  from  such  sources  have  been  brought  to  the  attention 


TYPHOID    CARRIERS  433 

of  the  medical  profession,  infection  generally  occurring  through  the  milk 
supply  or  through  food  prepared  by  such  a  typhoid  carrier.  The 
proportion  of  chronic  carrieis  has  been  estimated  at  from  1.7  per  cent, 
to  as  high  as  6  per  cent,  of  the  total  number  of  typhoid  cases  (Garbat, 
T916).  The  bacilli  have  been  found  in  the  livers  of  these  patients  at 
autopsy,  as  well  as  in  the  walls  of  the  gall-bladder  and  in  the  bile 
(Hammond,  1909).  The  typhoid  bacilli  may  remain  in  the  gall- 
bladder for  an  indefinite  period.  Gregg,  according  to  Kelly,  recovered 
the  bacillus  fifty- two  years  after  the  subsidence  of  the  acute  attack; 
and  Jundell  (1908)  reported  twenty-two  cases  of  infection  extending 
over  a  period  of  fifty-four  years,  arising  from  a  "carrier"  who  herself 
had  never  had  an  attack  of  typhoid  fever. 

The  diagnosis  of  "chronic  carrier"  is  not  made  from  any  symp- 
toms referable  to  the  gall-bladder  or  gall-ducts.  Usually  the  patients 
are  perfectly  normal  symptomatically,  so  far  as  the  liver  and  biliary 
tract  are  concerned.  The  only  positive  means  of  diagnosis  is  finding 
the  bacilU  in  the  stools  of  the  suspected  "carrier,"  or  in  the  duodenal 
contents.  The  latter  is  the  more  reliable  method  if  the  bacilli  have 
their  habitat  in  the  biliary  tract.  It  must  be  remembered,  however, 
that  cases  have  been  reported  in  which  the  intestinal  tract  appeared  to 
harbor  the  infection,  the  bile  itself  being  normal. 

In  spite  of  the  occasional  success  of  non-operative  treatment,  as 
mentioned  at  page  427,  we  believe  that  operation  is  indicated  in  the 
majority  of  typhoid  carriers.  The  operation  should  consist  in  chole- 
cystectomy and  drainage  of  the  hepatic  duct  as  advocated  by  Kehr 
(1913);  if  after  operation  repeated  tests  show  the  bile  coming  from  the 
liver  to  be  sterile,  it  may  be  safely  assumed  that  the  gall-bladder 
contained  the  infecting  focus;  if  the  bile  remains  infected,  only  pro- 
longed external  drainage,  as  in  other  cases  of  cholangeitis,  will  procure 
its  sterilization.  In  the  latter  cases  vaccine  or  other  medical  treatment 
may  prove  efficient  after  external  drainage  of  the  bile  even  if  employed 
without  success  previous  to  operation.  For  the  rare  instances  of 
intestinal  typhoid  carriers,  operative  treatment  so  far  as  we  are  aware, 
has  not  been  adopted;  but  it  is  logical  to  suppose  that  drainage  of  the 
tower  ileum  (ileostomy)  or  cecum  {cecostomy)  might  be  curative.  The 
Ireatment  of  typhoid  carriers  whose  urinary  tract  is  infected,  and  in 
whom  the  kidney  is  the  focus,  does  not  come  within  the  scope  of  this 
work. 

Few  surgeons  have  had  opportunity  to  operate  on  more  than  one  or 
at  most  two  typhoid  carriers,  and  results  in  isolated  case  reports  are 
apt  to  be  misleading.     Nichols,  Simmons  and  Stimmc!  (1919),  how- 

28 


434  SURGICAL    DISEASES    OF    THE    BILIARY    TRACT 

ever,  report  a  consecutive  series  of  six  chronic  typhoid  carriers  from  the 
Walter  Reed  General  Hospital:  one  (a  "urinary"  carrier)  was  cured  by 
nephrectomy,  three  were  cured  by  cholecystectomy,  and  two  failed  of 
cure  by  cholecystectomy.  It  is  to  be  noted,  however,  that  the  im- 
portance of  hepatic  duct  drainage  was  not  generally  recognized  at  the 
time  these  operations  were  done;  better  results  may  be  anticipated 
in  the  future. 

Jaundice  as  a  Symptom 

Jaundice  as  a  sign  or  s}-mptom  is  always  of  importance  to  the 
surgeon.  The  term  signifies  a  peculiar  discoloration  of  the  tissues  by 
bile-pigment.  It  is  not  a  pathological  entity,  but  a  symptom  of  a 
number  of  lesions  that  are  found  in  connection  with  diseases  of  the 
liver  and  bile-passages,  or  the  structures  adjacent  to  them. 

In  a  healthy  individual,  bile-pigment  is  found  only  in  the  bile. 
Under  normal  conditions  these  pigments  are  formed  in  the  Hver; 
and  the  hver  or  its  excretory  ducts  are  involved  clinically,  with  very 
rare,  if  any,  excpetions,  in  every  case  of  jaundice.  It  is  essential 
for  the  diagnostician  to  differentiate  between  those  cases  requiring 
surgical  treatment  and  those  that  will  be  relieved  by  medical  measures 
alone. 

In  the  majority  of  cases  jaundice  results  from  absorption   of  bile 
from  the  small  radicles  of  the  bile-ducts,  due  to  obstruction  of  these 
channels.     \\'hen  it  is  realized  that  the  secretion-pressure  of  the  bile 
amounts  to  only  200  mm.  of  water,  it  is  evident  that  even  slight  obstruc- 
tion to  the  flow  of  bile  will  overcome  its  secretion-pressure.     When 
obstruction  exists  in  the  bile-passages,  either  intrahepatic  or  extrahe- 
patic,  there  is  a  damming  up  of  the  bile  in  the  proximal  portions  of  the 
ducts  extending  as  far  as  the  capillary  radicles.     As  the  secretion  of 
bile  continues,  increased  dilatation  of  the  ducts  follow.     The  capil- 
laries gradually  become  lengthened  and  distended  until  they  rupture 
into   the  adjoining  lymph-spaces.     The  bile-pigments  are   then  ab- 
sorbed by  the  lymphatics,  and  are  carried  to  the  thoracic  duct  and  into 
the  general  circulation.     That  the  bile-pigments  arc  carried  to  the 
blood  through  the  thoracic  duct  has  been  repeatedly  demonstrated 
(Kelly,  1908).     After  the  common  bile-duct  is  ligated  bile-pigments  are 
soon  recovered  through  a  fistula  in  the  thoracic  duct;  when  both  thoracic 
and  common  ducts  are  ligated,  thus  preventing  the  adminsion  of  bile 
into  the  general  circulation  through  the  thoracic  duct,  discoloration 
of  the  skin  is  seldom  seen,  and  the  bile-pigments  do  not  appear  in  the 
urine  for  several  days.     It  is  also  possible  for  the  bile-pigments  to 


SIGNIFICANCE    OF    JAUNDICE  435 

enter  the  systemic  circulation  through  the  intrahepatic  capillaries 
(Quincke,  1903). 

There  are  numerous  instances  of  icterus  occurring  in  patients  where 
it  is  impossible  to  demonstrate  an  obstruction  to  the  bile-ducts.  In 
such  cases  the  manner  of  absorption  of  the  bile-pigments  is  not  so 
plain.  But  it  is  probable  that  the  mechanism  is  much  as  described 
above,  although  various  theories  have  been  advanced  to  account  for 
the  occurrence  of  jaundice  when  no  obstruction  is  evident.  According 
to  Kelly,  Eppinger  believed  that  obstruction  takes  place  even  in  these 
instances,  but  only  in  the  most  minute  radicles  of  the  bile-channels: 
stasis  of  bile  occurs  and  there  is  dilatation  of  the  biHary  canahcuH  with 
final  rupture  into  the  pericellular  lymph-spaces. 

In  some  instances  of  injury  to  the  liver  or  gall-ducts  with  escape  of 
free  bile  into  the  peritoneal  cavity,  jaundice  follows  its  absorption. 
If  there  is  a  chronic  peritonitis  present,  however,  the  peritoneum  will 
be  incapable  of  absorbing  the  bile-pigments,  and  jaundice  may  not 
occur. 

The  presence  of  bile-pigments  in  the  circulating  blood  gives  rise 
to  certain  symptoms  which  are  entirely  independent  of  the  primary 
cause  of  the  condition.  These  are  most  marked  in  obstructive  jaundice, 
and  vary  somewhat  in  degree  with  the  completeness  of  the  obstruction. 
The  most  noticeable  symptom  produced  is  discoloration  of  the  skin 
and  visible  mucous  membranes.  In  the  onset  of  icterus  the  color  is 
generally  a  light  yellow,  gradually  changing  to  a  greenish  tint,  and 
terminating  in  a  yellowish-gray.  The  natural  pigmentation  of  the 
skin  will  often  mask  the  lighter  degrees  of  jaundice,  so  that  it  is  often 
overlooked  in  brunettes.  The  sclerae,  as  a  rule,  are  discolored  more 
rapidly  than  the  skin.  In  many  patients  a  subicteroid  tint  of  the  skin 
is  an  evidence  of  a  mild  chronic  cholangeitis;  such  patients  may  never 
have  had  a  true  jaundice  and  it  may  have  been  thought  they  were 
merely  swarthy. 

Itching  of  the  skin  is  more  or  less  prominent  as  a  symptom  of  icterus, 
often  preceding  the  discoloration,  although  as  a  rule  it  follows  the  latter 
condition.  There  is  no  relation  between  the  intensity  of  the  discolora- 
tion of  the  skin  and  the  degree  of  pruritus. 

It  is  said  that  xanthoma  (xanthelasma)  may  occur  in  chronic  lithi- 
asis  with  jaundice.  This  skin  lesion  is  not  peculiar  to  jaundice  although 
often  seen  in  connection  with  it.  It  consists  of  pale  yellowish  spots, 
found  chiefly  in  the  region  of  the  eyelids,  the  areas  of  discoloration 
being  raised  above  the  level  of  the  surrounding  skin.  According  to 
Quincke  the  3'ellowish  pigmentation  of  these  spots  is  not  caused  by 


436  SURGICAL    DISEASES    OF    THE   BILIARY    TRACT 

bile-pigments,  nor  has  their  connection  with  icterus  been  definitely 
determined. 

The  discoloration  of  jaundice  is  frequently  observed  first  on  the 
visible  mucous  membranes,  especially  the  scleral  conjunctivas.  This 
change  is  not  always  apparent  on  the  other  mucous  membranes  except 
on  the  lips  and  hard  palate,  where  the  membrane  is  naturally  more  or 
less  pale.  It  usually  can  be  demonstrated  on  the  visible  mucous  mem- 
branes by  depriving  them  of  their  blood  by  pressure,  as  by  that  of  a 
thin  glass  slide  against  the  everted  lower  lip.  But  the  discoloration  of 
jaundice  may  often  be  apparent  on  the  abdomen  when  not  noticeable 
in  the  conjunctivae. 

The  excretion  of  the  greater  part  of  the  bile-pigments  through  the 
kidneys  results  in  discoloration  of  the  urine,  the  color  varying  from 
yellowish,  through  yellowish- red,  to  a  greenish-brown  depending  to  a 
great  extent  upon  the  presence  of  the  different  pigments  and  their 
products.  This  discoloration  of  the  urine  is  generally  seen  before  the 
pigmentation  of  the  skin,  preceding  the  latter  at  times  by  several  days, 
being  in  reality  the  first  clinical  s^rmptom  of  jaundice.  It  can  be 
demonstrated  by  the  discoloration  of  the  froth  after  a  brisk  shaking  of 
the  urine;  and  often  by  the  staining  of  the  filter-paper  through  which 
the  urine  is  passed.  The  more  delicate  tests  are  given  in  text-books  of 
medicine  and  in  laboratory  manuals. 

In  protracted  cases  of  jaundice,  the  urine  may  be  diminished 
in  amount,  with  increase  in  the  specific  gravity.  Hj'aline  casts, 
at  times  bile-stained,  are  found. 

The  pale  "acholic"'  stools  of  a  jaundiced  patient  are  another  diagnos- 
tic sign  (p.  4;, 7). 

Hemorrhage  in  Cases  of  Jaundice. — Bile-pigments  are  present 
in  the  blood  in  every  case  of  jaundice  but  their  action  on  the  blood  has 
not  been  definitely  determined.  Jaundice,  especially  if  of  long  duration, 
is  attended  by  an  impoverished  condition  of  the  blood  with  a  diminu- 
tion in  the  number  of  erythrocytes  and  in  the  amount  of  hemoglobin. 
There  is  also  present  a  decided  prolongation  in  the  coagulation  time  of 
the  blood.  This  will  be  increased  from  the  normal,  three  or  four  minutes, 
to  as  much  as  fifteen  minutes  and  even  longer.  This  condition  may 
depend  upon  a  change  in  the  fibrin  ferment,  upon  alterations  that  occur 
in  the  red  blood-cells,  or  may  be  due  to  the  mere  presence  of  the  bile- 
pigments  and  bile-acids.  When  this  condition  is  present  there  may 
be  bleeding  from  the  mouth,  the  nose,  the  intestines,  the  bronchi, 
the  kidneys,  and  into  the  skin.  After  operation  there  is  sometimes  an 
oozing  from  the  wound  which  will  continue  until  the  ))atient  is  exsan- 


HEMORRHAGE   IN    CASES    OF   JAUNDICE  437 

guinated.  The  oozing  may  be  absolutely  uncontrollable.  This  bleed- 
ing may  not  begin  at  the  time  of  the  incision;  the  wound  may  be  dry 
when  closed  but  two,  three  or  even  four  days  after  the  operation 
the  dressings  may  be  found  soaked  with  blood,  by  an  uncontrollable 
oozing  that  sometimes  continues  until  the  death  of  the  patient.  This 
danger  cannot  be  prevented ,  but  perhaps  it  may  be  lessened  by  the  admin- 
istration of  calcium  chloride  in  2-gramme  doses  every  three  or  four  hours 
for  a  day  or  more  before  the  operation,  by  mouth,  and  4-gramme  doses 
after  the  operation,  by  rectum.  Calcium  chloride  reduces  the  coagulation 
time  of  the  blood  but  it  does  not  always  suffice  to  prevent  the  oozing. 
Transfusion  of  blood,  a  remedy  which  is  available  in  all  well  equipped 
hospitals,  is  the  most  certain  remedy  known.  When  this  method  can- 
not be  employed,  some  form  of  ready  prepared  alien  serum  should  be 
injected  hypodermically  or  intravenously.  Anti-diphtheritic  serum 
usually  may  be  procured,  and  should  be  used  in  doses  of  from  5000  to 
10,000  units,  or  horse  serum  may  be  administered  two  or  three  times 
daily  in  doses  of  10  to  30  cc.  for  several  days  after  operation. 

The  absence  of  bile -pigments  from  the  stools  will  cause  the  excreta 
to  be  lighter  in  color  than  normal;  their  complete  absence  produces 
the  well-known  "clay-colored  stools.."  Variations  in  the  color  of  the 
stools,  showing  alternately  the  presence  and  absence  of  bile-pigments 
indicates  an  intermittent  obstruction  to  the  flow  of  bile,  a  condition 
that  is  found  in  the  so-called  "ball-valve"  obstruction  of  the  common 
duct  by  a  calculus.  When  obstruction  is  due  to  a  tumor,  such  as  cancer 
of  the  head  of  the  pancreas,  the  obstruction  does  not  vary;  the  stools 
remain  constantly  free  from  bile-pigments,  and  are  of  a  grayish  color. 

The  color  of  the  stools  seen  in  jaundice  is  partly  due  to  an  increase 
of  the  undigested  fats  which  may  increase  from  normal  (7  to  10  per 
cent.)  to  as  high  as  80  per  cent. 

To  comprehend  the  true  significance  of  jaundice  as  a  symptom  in 
surgical  diseases  of  the  liver  and  biliary  passages,  we  must  consider 
the  various  causes  which  will  give  rise  to  it,  and  the  frequency  with 
which  it  is  found  in  those  diseases  which  are  treated  by  the  surgeon. 
Icterus  occurs  whenever  there  is  a  more  or  less  prolonged  obstruction 
of  the  hepatic  or  common  duct,  from  any  cause.  It  occurs,  according 
to  Kelly  "under  other  circumstances — in  which  apparently  the  bihary 
ducts  are  patent,  as  in  cirrhosis  and  other  diffuse  diseases  of  the  liver; 
in  many  infections,  such  as  the  different  types  of  so-called  infectious 
jaundice,  syphilis,  yellow  fever,  septicopyemia,  malaria,  pneumonia, 
typhoid  fever,  etc.;  in  intoxications  such  as  poisoning  with  ptomains, 
phosphorus,  arseniuretted  hydrogen,  chloroform,  mushrooms,  toluyl- 


438  SURGICAL   DISEASES    OF    THE    BILIARY    TRACT 

enediamin,  pyrogallol,  snake  venom,  coal-tar  products,  etc.;  in 
acute  yellow  atroph\-  of  the  liver;  in  progressive  pernicious  anemia  and 
hemoglobinemia ;  in  disturbances  of  the  circulation,  such  as  passive 
congestion;  in  certain  nervous  perturbations  (so-called  emotional 
jaundice,  menstrual  jaundice,  etc.);  in  the  new-born,  etc." 

Hunter  (1897)  gave  the  following  classification  of  jaundice  not  due 
to  obstruction: 

1.  Jaundice  produced  by  the  action  of  poisons,  such  as 
phosphorus,  arsenic,  and  snake  venom. 

2.  Jaundice  met  with  in  various  specific  fevers  and  condi- 
tions, such  as  yellow  fever,  malaria  (remittent  and 
intermittent),  pyemia,  relapsing  fever,  typhus,  typhoid 
fever,  and  scarlatina. 

3.  Jaundice  met  with  in  various  conditions  of  unknown 
or  more  or  less  obscure,  infectious  nature,  and  variously 
designated  as  "epidemic,"  "'infectious,"  or  "malignant" 
jaundice,  "icterus  gravis,"  "Weil's  disease,"  and  "acute 
yellow  atrophy  of  the  hver." 

To  these  might  be  added  the"  jaundice  frequently  associated  with 
severe  hemorrhage,  with  starvation,  or  with  lowered  blood-pressure  in 
the  portal  or  hepatic  vessels  in  the  presence  of  increased  tension 
in  the  smaller  bile-ducts. 

The  following  is  a  convenient  classification  of  jaundice  due  to 
obstruction : 

1.  Obstruction  due  to  inflammatory  thickening  of  the  mucous 
membrane  of  the  ducts,  or  the  result  of  such  inflammation; 
rarely  to  tumors  of  the  ducts  themselves. 

2.  Obstruction  due  to  stone  in  the  common,  rarely  the  hepatic, 
duct;  or  in  the  cystic,  pressing  on  the  common  duct. 

3.  Obstruction  due  to  neoplastic  or  hyperplastic  conditions 
of  the  pancreas,  or  its  l}-mphatics,  especially  those  of  the  head 
of  this  organ. 

4.  Obstruction  due  to  neoplasms  or  to  pathological  conditions 
such  as  adhesions,  enlarged  tymph-nodes,  kinks,  etc.,  of 
neighboring  organs  exerting  pressure  onthe  common  duct. 

Jaundice  does  not  occur  in  every  case  of  biliary  tract  disease,  but 
a  carefully  taken  history  wiU  show  that  it  has  been  present  at  some 
period  of  the  disease  in  about  65  per  cent,  of  the  cases,  and  has  not 


JAUNDICE    AS    A    SYMPTOM  439 

been  noted  in  about  35  per  cent.  At  the  time  of  operation,  in  our  own 
experience,  jaundice  is  present  only  in  about  one-third  of  the  patients. 
Mayo,  however,  has  stated  that  jaundice  was  present  in  70  per  cent,  of 
his  patients  at  the  time  of  operation. 

Jaundice  is  a  symptom  and  not  a  disease;  in  every  case  there  is  a 
lesion  to  account  for  the  presence  of  this  symptom,  but  great  difficulty 
is  often  encountered  in  determining  just  what  this  lesion  is.  A  complete 
history  and  careful  study  of  the  accompanying  symptoms  will,  in  the 
majority  of  cases,  make  the  diagnosis  clear;  in  other  cases  an  exploratory 
operation  will  be  necessary. 

The  following  aphorisms  may  be  of  assistance  in  determining  the 
cause  of  jaundice: 

Jaundice  which  is  slight  and  persists  most  probably  is  independent 
of  obstruction. 

Jaundice  from  obstruction  becomes  intense  very  rapidly. 
Jaundice  coming  on  gradually  but  ultimately  becoming  intense, 
with  clay-colored  stools,  generally  is  due  to  pressure  from  neighboring 
structures,  especially  to  diseases  of  the  pancreas,  such  as  pancreatic 
lymphangeitis,  chronic  interstitial  pancreatitis,  or  carcinoma  of  the 
pancreas. 

Jaundice  which  does  not  persist  indefinitely  or  which  recurs  time  and 
again,  generally  is  due  to  calculous  obstruction. 

Jaundice  with  sudden  onset,  accompanied  by  colicky  pains  and 

clay-colored  stools,  generally  is  due  to  obstruction  within  the  gall-ducts. 

Jaundice  following  severe  paroxysms  of  pain  generally  is  due  to 

gall-stone  formation  or  to  carcinoma.     In  the  latter  case  there  should 

be  a  history  of  faihng  health  before  the  onset  of  pain  or  jaundice. 

Jaundice  in  the  presence  of  an  enlarged  liver  generally  is  due  to 
cirrhosis  of  the  liver,  to  cancer  of  the  liver,  or  to  pyemic  abscess  of  the 
liver. 

Jaundice  with  ascites  generally  is  due  to  cancer  of  the  liver  or 
to  cirrhosis.  In  the  former  there  are  darting  pains,  loss  of  weight 
and  intense  jaundice.  In  cirrhosis  there  generally  is  a  history  of 
alcoholic  dyspepsia;  the  jaundice  is  generally  much  less  intense  than  in 
cancer. 

Jaundice  with  pyrexia  is  secondary  either  to  acute  febrile  infection, 
to  suppurative  pylephlebitis,  or  to  inflammation  of  the  bile-ducts. 
Temporary  pyrexia  may  be  caused  by  the  passage  of  a  stone  through 
the  bile-ducts. 

Jaundice  with  a  history  of  previous  attacks  generally  is  due  to  a 
catarrhal  condition  of  the  bile-ducts  or  to  the  presence  of  gall-stones. 


440  SURGICAL   DISEASES    OF   THE   BILIARY    TRACT 

Jaundice  with  cerebral  symptoms  generally  is  due  to  acute  atrophy 
of  the  liver,  to  poisoning  by  phosphorus,  or  to  some  specific  fever  such 
as  pneumonia. 

Jaundice  in  a  young  person  preceded  by  s^Tnptoms  of  gastric 
catarrh  generally  is  "catarrhal  jaundice"  (page  445). 

Jaundice  which  is  intermittent,  at  times  slight  and  again  intense, 
with  urine  that  varies  in  color  from  light  to  dark,  with  stools  that 
are  intermittently  dark  and  clay-colored,  with  colicky  pains,  with  chills 
and  fever  similar  to  those  of  malaria,  almost  invariably  is  due  to  chronic 
calculous  obstruction  of  the  common  duct. 

Jaundice  with  fatty  stools,  in  the  presence  of  glycosuria,  is  generally 
indicative  of  pancreatic  disease. 

Jaundice  increasing,  without  remissions,  with  marked  dyspep- 
tic s\'mptoms,  with  marked  increase  in  neutral  fats  in  the  stools,  with 
undigested  muscle  fibres  with  nuclei  intact  in  the  stools,  is  due  to 
pancreatic  disease. 

Jaundice  following  general  failure  of  health,  increasing  until  it 
becomes  absolute  and  never  varying,  with  a  greenish  tint,  mth  rapid 
loss  of  weight,  with  a  distended  gall-bladder,  with  gradual  and  painless 
onset,  generally  is  due  to  carcinoma  of  the  head  of  the  pancreas. 

In  jaundice  due  to  obstruction,  either  internal  or  external,  the 
stools  are  clay-colored  or  hghter  in  color  than  normal,  either  con- 
tinuously or  intermittently. 

In  jaundice  not  due  to  obstruction  of  the  bile-ducts,  the  stools 
are  not  clay-colored.  It  must  be  remembered  that  certain  drugs, 
such  as  bismuth,  iron,  and  charcoal  will  color  the  stools;  altered,  dis- 
integrated blood  in  the  stools  will  also  change  the  color. 

Jaundice  is  seen  in  non-calculous  cholecystitis  only  after  the  in- 
flammatory process  in  the  gall-bladder  has  extended  to  the  mucous 
membrane  of  the  cystic  and  common  ducts. 

The  significance  of  jaundice  as  a  symptom  in  various  diseases 
of  the  hver  and  biliarj'  tract  will  be  considered  more  fully  in  the  sections 
devoted  to  those  lesions. 


CHAPTER  XVII 
SURGERY  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Deformities,  Anomalies  and  Malpositions 

Congenital  Obliteration  of  the  Bile-ducts. — The  absence  of  a 
passageway  for  the  bile,  at  birth,  usually  is  the  result  of  obliteration  or 
atresia  of  the  common  bile-duct.  Lavenson  (1908)  suggested  that 
the  condition  is  a  true  atresia,  and  not  an  "obliteration,"  the  latter 
presupposing  the  existence  of  a  lumen  which  subsequently  becomes 
destroyed.  The  condition,  although  unusual,  is  not  rare.  Holmes 
(1916)  collected  108  authentic  cases  from  the  literature. 

Paul  Mathieu  (1908)  collected  eight  authentic  and  twelve  doubtful 
cases  of  congenital  stricture  of  the  bile-ducts;  the  stricture  usually 
has  been  at  or  near  the  duodenal  termination  of  the  common  duct. 

Other  rare  anomalies  include  cases  where  there  is  more  than  one 
common  duct,  cases  where  one  or  more  of  the  bile-ducts  open  into 
the  stomach  or  at  an  unusual  point  in  the  intestine,  and  anomalies 
in  the  number  and  situation  of  the  hepatic  ducts. 

Pathologically,  there  is  an  obstruction,  atresia,  or  obliteration  of 
the  common  duct,  with  cirrhosis  of  the  liver.  Lavenson  thought 
the  cirrhosis  is  the  result  of  the  obliteration  and  consequent  bile  stasis; 
Rolleston  (1907)  supported  the  view  that  the  cirrhosis  precedes  the 
obstruction,  a  descending  cholangitis  causing  obliteration  of  the  lumen 
of  the  duct.  As  pointed  out  by  Rolleston,  other  causes  of  stricture 
must  be  recognized,  such  as  fetal  peritonitis,  with  its  resulting  adhesions; 
or  obstruction  of  the  ducts  by  syphilitic  granulation  tissue,  as  in  a  case 
under  his  own  care. 

The  classification  of  these  cases  of  infantile  jaundice  which  has 
been  adopted  by  Mathieu  is  convenient.  He  classifies  them  in  two 
main  divisions:  (i)  Those  in  which  the  condition  is  not  compatible 
with  life  (congenital  occlusion  or  total  absence  of  the  bile-duct) ;  and 
(2)  cases  compatible  with  life,  including  both  {a)  congenital  icterus 
without  lesion  of  the  bile-ducts  (which  may  be  attributed  to  angiocho- 
litis  of  the  intrahepatic  ducts  or  to  splenic  disease  causing  jaundice 
by  hemolysis),  and  {b)  those  cases  already  mentioned,  in  which  stricture 
but  no  absolute  occlusion  of  the  ducts  exists. 

441 


442  SURGERY   OF    THE    GALL-BL.^DDER   AND   BILE-DUCTS 

Clinically  congenital  obstruction  of  the  common  duct  is  char- 
acterized by  jaundice  which  generally  is  present  at  birth,  although 
it  may  not  develop  for  some  weeks.  The  jaundice  increases  in  in- 
tensity, the  urine  contains  bile  and  the  stools  are  free  from  all  bile- 
coloring  matter.  The  liver  and  spleen  generally  are  enlarged. 
Hemorrhage  from  the  cord  may  occur,  and  purpuric  spots  may  be 
seen.  Emaciation  rapidly  ensues,  with  coma,  stupor,  and,  at  times, 
con\Tilsions  followed  by  death.  One  case  reported  (Treves)  where 
the  patient  lived  nineteen  years  with  continuous  jaundice  for  sixteen 
years. 

The  diagnosis  is  not  readily  made.  The  condition  may  be  dis- 
tinguished from  icterus  neonatorum  by  the  short  duration  of  the 
latter,  and  the  presence  in  that  disease  of  bile  in  the  stools  and  its 
absence  from  the  urine  (Griffith,  1908).  In  the  jaundice  of  the  new- 
born due  to  a  simple  catarrhal  duodenitis  or  cholangitis,  there  always 
is  some  degree  of  fever,  which  usually  is  absent  in  cases  of  icterus 
due  to  congenital  anomaly  or  stricture.  Partial  occlusion  of  the 
duct  causing  jaundice  which  ultimately  will  clear  up  cannot  be  distin- 
guished until  time  has  proved  the  diagnosis.  A  duodenal  catheter 
is  an  aid  in  diagnosis:  being  passed  through  the  stomach  and  pylorus, 
the  duodenal  contents  are  pumped  out,  and  are  examined  for  bile, 
pancreatic  juice,  etc.  In  Hess's  patient  life  was  preserved  for  three 
months,  possibly  because  the  accessory  duct  of  the  pancreas  was 
patulous.  Though  tests  made  during  hfe  showed  the  presence  of  bile 
in  the  duodenal  contents,  complete  occlusion  of  the  common  duct  was 
found  at  autopsy;  and  Hess  suggests  that  perhaps  bile  may  be  excreted 
from  the  circulation  through  the  intestinal  canal. 

The  treahnent  is  operative,  although  antisyphilitic  treatment 
should  be  instituted  in  the  hope  that  the  condition  is  due  to  con- 
genital syphihs,  even  if  the  history  of  the  patient  is  negative.  The 
surgical  procedure  necessary  will  be  some  form  of  anastomosis  between 
the  gall-bladder  or  the  upper,  unobhterated  portion  of  the  duct,  and 
the  duodenum  (page  510).  Lavenson  collected  reports  of  four  unsuc- 
cessful attempts  at  operative  relief. 

Congenital  Absence  of  the  Gall-bladder. — Although  the  gall- 
bladder is  not  essential  to  hfe  and  is  entirely  absent  in  some  of  the 
lower  animals,  such  as  the  rhinoceros,  the  camel,  the  goat,  the  deer 
and  the  elephant,  its  congenital  absence  in  man  is  rarely  noted. 
Nearlj'  all  of  the  important  information  upon  the  subject,  as  pointed 
out  by  Stone  (1908),  has  been  assembled  bj-  F.  Fink  (1904)  and  A. 
Bubenhofer  (1905).     In  most  of  the  cases  reported  as  such,  as  pointed 


ANOMALIES    AND    MALFORMATIONS  443 

out  by  Eshner  (1894),  "the  absence  of  the  gall-bladder  was  associated 
with  conditions  that  point  to  obliteration  of  a  previously  existing 
viscus,  rather  than  to  a  condition  of  agenesis."  Eshner  reported 
the  case  of  a  child  who  came  under  his  observation  for  a  persistent 
cough.  The  bowels  moved  several  times  daily,  the  stools  being  pale. 
No  jaundice  was  present.  The  patient  died  when  two  years  of  age. 
and  at  autopsy  the  liver  was  found  to  be  of  normal  size  and  condition, 
although  changes  probably  syphilitic  in  origin  were  apparent.  The 
biliary  vessels  and  ducts,  with  the  exception  of  the  cystic  duct,  were 
normal.  The  gall-bladder  was  absent,  the  usual  fissure  for  the  gall- 
bladder was  wanting,  and  there  was  nothing  suggestive  of  the  gall- 
bladder ever  having  been  present.  Gay  (1902)  collected  nineteen 
cases  of  absence  of  the  gall-bladder;  in  six  of  them  "absence"  was 
the  only  abnormality.  Stone's  patient  was  a  woman  fifty-four  years 
of  age  upon  whom  an  operation  was  performed  under  the  diagnosis  of 
calculous  cholecystitis,  with  obstruction  of  the  common  duct.  A  pal- 
pable mass  was  thought  to  be  the  gall-bladder  filled  with  calculi.  Upon 
opening  the  abdomen  the  gall-bladder  was  conspicuously  absent, 
the  duodenum  and  pylorus  being  attached  to  the  normal  site  of  that 
viscus.  No  adhesions  were  present.  Calculi  were  readily  palpated 
in  the  common  and  hepatic  ducts.  After  the.  ducts  had  been  opened 
and  the  stones  removed,  search  for  the  gall-bladder  was  made  but  it 
could  not  be  found.  Exploration  with  a  probe  through  the  hepatic 
duct  failed  to  reveal  any  vestige  of  the  cystic  duct.  Niemack  (1908) 
has  reported  a  case  of  cholesterin  stone  in  the  common  duct  in  a  patient 
in  whom  he  could  not  find  a  gall-bladder. 

The  condition  does  not  present  any  sign  or  symptoms  that  might 
lead  to  a  correct  diagnosis.  The  diagnosis  is  made  either  at  the 
operating-table  or  postmortem.  The  treatment  of  the  cases  subjected 
to  operation  should  be  directed  to  the  condition  for  which  the  opera- 
tion is  performed. 

Anomalies  in  position  and  shape  of  the  gall-bladder  are  not  com- 
mon. Constrictions,  sacculations  and  other  deviations  from  the 
normal  shape  of  the  viscus  may  be  the  result  of  inflammatory  changes; 
the  organ  may  become  enormously  distended  as  a  result  of  obstruction 
of  the  cystic  duct  or  may  become  practically  obliterated  by  cicatricial 
contraction.  Many  of  the  cases  of  "hour-glass"  gall-bladders  that 
have  been  reported  may  be  the  result  of  a  defect  in  development  or  the 
effect  of  cicatricial  contraction.  The  gall-bladder  may  be  bi-lobed, 
may  be  transversely  placed,  may  be  imbedded  in  the  Uver  substance, 
or  may  be  freely  movable  owing  to  the  presence  of  a  distinct  mesentery. 


444  SURGERY    or    THE    GALL-BLADDER    AND    BILE-DUCTS 

This  condition  is  described  as  wandering  gall-bladder,  and  is  not  ex- 
ceptionally rare.  Kiibig  (191 2)  noted  having  seen  two  cases  at  autopsy. 
Its  importance  arises  from  the  fact  that  it  predisposes  to  torsion  or 
volvulus  of  the  gall-bladder. 

Sherren  (1911),  who  successfully  removed  at  operation  a  double 
gall-bladder,  refers  to  the  autopsy  reported  by  Purser  (1886J  as  the 

only  case  where  there  existed  two 
complete  gall-bladders  with  separate 
cystic  ducts;  Purser  himself  quotes 
from  the  Philosophical  Transactions 
( 1693-94)  a  case  where  at  postmortem 
there  were  found  two  distinct  gall- 
bladders, one  in  the  right  lobe  and 
the  other  in  the  left  lobe  of  the  hver. 
Schachner  (191 7)  collected  five  cases, 
.~— '*  including  his  own  patient  in  whom 
Fig.    136.  — Hour-Giass  Gall- Bladder,    he  drained  both  gall-bladders  with 

From  a  Patient  in  theLankenau  (formerly     .„t,vfopfr,r,r  result 
German)  Hospital.  SatlSlaCtOry  reSUll. 

Several  cases  of  hour-glass  gall- 
bladder are  on  record.  The  following  case  was  observed  at  the 
Lankenau  Hospital. 

Hour-glass  Gall-bladder. — \.  S.,  female,  aged  thirty  five;  operation.  May  24, 
1904.  Adhesions  between  the  gall-bladder  and  stomach.  These  were  ligaled  and 
cut,  and  the  gall-bladder  was  found  to  be  "hour-glass"  in  shape,  both  pouches 
being  filled  with  calculi  (Fig.  1,56).  Cholecystectomy  was  performed,  the  patient 
recovering. 

Chol.^ngeitis  and  Cholecystitis 

A  thorough  knowledge  of  the  etiology  and  pathology  of  the  infec- 
tious diseases  of  the  biliary  tract  is  essential  for  the  correct  interpreta- 
tion of  their  signs  and  symptoms.  These  vary  greatly  with  the  different 
pathological  processes,  and  an  accurate  diagnosis  can  be  made,  the 
proper  treatment  instituted,  and  the  ultimate  outcome  predicted,  only 
through  a  correct  interpretation  of  their  significance.  In  some  instances 
the  lesions  are  varied  and  multiple,  being  diagnosticated  correctly 
only  after  direct  inspection  and  palpation.  In  the  majorty  of  cases, 
however,  a  study  of  the  signs  and  symptoms  present  will  enable  the 
surgeon  to  make  a  correct  diagnosis. 

All  non-neoplastic  surgical  diseases  of  the  biliary  tract  are  the  result 
of  bacterial  infection.^     Infection  of  the  biliary  tract  gives  rise  to  in- 

1  For  a  full  description  of  the  bacteria  found  in  the  biliary  tract  and  their  paths  of 
entrance,  see  page  415. 


PATHOGENESIS    OF    CHOLANGEITIS  445 

flammatory  changes  in  its  component  parts,  the  mildness  or  severity 
of  the  lesion  produced  depending  upon  the  virulence  of  the  bacteria 
and  the  resistance  of  the  patient.  Mild  or  severe  cholangeitis,  mild  or 
severe  cholecystitis,  with  or  without  the  formation  of  biliary  calculi,  will 
follow.  At  times  the  infection  is  so  slight  and  so  readily  thrown  off  by 
the  involved  structures  that  no  permanent  pathological  lesions  result. 
In  other  instances  the  onset  and  course  of  the  infection  are  very  insidi- 
ous, the  resulting  chronic  inflammation,  gall-stone  formation,  etc.,  not 
giving  rise  to  important  symptoms  until  many  years  after  the  true 
commencement  of  the  disease. 

Infections  of  the  biliary  ducts  and  gall-bladder  usually  coincide. 
Infection  of  the  gall-bladder  may  precede  that  of  the  ducts,  but  usually 
the  ducts  are  first  affected;  the  infection  in  the  ducts  may  subside  while 
that  in  the  gall-bladder  continues;  but  infection  of  one  without  infection 
of  the  other  is  rare.  The  results  of  the  infection,  however,  vary 
greatly:  thus  pathological  lesions  which  result  from  infection  of  the 
gall-bladder  without  serious,  or  with  quickly  subsiding  infection  of  the 
bile-ducts,  are  very  different  from  those  seen  when  the  bile-channels  are 
permanently  diseased.  With  involvement  of  the  common  and  hepatic 
ducts,  lesions  of  varying  degrees  of  severity  are  always  found  in  the  liver; 
when  the  gall-bladder  alone  is  infected,  the  liver  is  seldom  involved. 
Infection  of  the  ducts  gives  rise  to  hepatic  and  perihepatic  lesions; 
infection  of  the  gall-bladder  without  involvement  of  the  ducts,  gives 
rise  to  pericholecystic  lesions. 

Cholangeitis. — The  simplest  form  of  infection  of  the  bile-ducts 
causes  acute  catarrhal  cholangeitis.  Usually  this  has  the  same  eti- 
ology as  gastro-intestinal  catarrh,  which  often  is  described  by  its 
most  striking  symptom,  as  "catarrhal  jaundice."  Cholangeitis 
frequently  is  a  complication  or  sequel  of  this  condition.  It  is  also 
observed  in  connection  with  some  of  the  infectious  diseases,  such  as 
typhoid  fever  and  pneumonia;  it  may  result  from  interference,  by 
various  toxins,  with  the  normal  activity  of  the  ultimate  radicles  of  the 
ducts  in  the  hver,  or  with  the  metabohsm  of  the  liver  cells;  it  may  occur 
in  cirrhosis  of  the  liver,  or  in  advanced  heart  disease. 

Catarrhal  jaundice  is  essentially  obstructive  jaundice.  In  the 
acute  condition  the  duodenal  mucous  membrane  around  the  bile- 
papilla,  and  that  in  the  lower  end  of  the  common  duct,  become  swollen 
and  edematous  and  cause  partial  obstruction  of  the  biliary  outlet;  this 
is  followed  by  jaundice  of  varying  intensity.  At  times  a  plug  of  mucus 
in  the  diverticulum  of  Vater  is  the  cause  of  obstruction.  Eppinger, 
in  a  case  of  catarrhal  jaundice  which  came  to  autopsy  as  the  result  of 


446  SURGERY    OF    THE    GALL-BLADDER   AND   BILE-DUCTS 

an  accident  eight  days  after  the  onset  of  jaundice,  found  hyperplasia 
of  the  lymphoid  tissues  of  the  mucous  membrane  in  the  portion  of  the 
common  duct  which  transverses  the  intestinal  wall.  This  had  led 
to  complete  obstruction  of  the  duct  and  dilatation  of  the  rest  of  the 
biliary  system. 

Mild  jaundice,  of  the  catarrhal  type,  may  be  of  surgical  significance 
when  a  complication  or  sequel  of  echinococcus  cysts,  gummata,  car- 
cinoma of  the  liver,  etc.,  where  the  jaundice  results  from  obstruction 
caused  by  pressure  on  the  ducts  from  without.  Mayo  Robson  (1908) 
thought  that  in  many  cases  of  catarrhal  jaundice  the  head  of  the 
pancreas  is  inflamed  and  that  the  pressure  of  this  upon  the  common  bile- 
duct  is  sufficient  to  cause  obstruction.  These  cases,  however,  usually 
are  more  properly  classed  as  chronic  catarrhal  cholangeitis. 

Acute  catarrhal  cholangeitis  is  of  interest  to  the  surgeon  from  a 
diagnostic  standpoint.  In  the  early  stages,  as  a  rule,  the  condition  is 
hidden  by  the  usual  symptoms  of  gastro-intestinal  catarrh,  such  as  loss 
of  appetite,  coated  tongue,  foul  breath,  headache,  nausea  and  vomiting. 
The  temperature  may  rise  to  100°  F.  or  101°  F.,  or  higher  in  rare  cases, 
the  patient  also  ha\'ing  rigors  and  sweats.  Jaundice  appears  in  from 
two  to  seven  days,  being  first  noticed  in  the  sclera.  With  the  onset 
of  jaundice,  as  a  rule,  the  temperature  falls  to  normal  or  even  subnor- 
mal; the  stools  become  clay-colored,  and  the  urine  scanty  and  highly 
colored.     The  liver  may  be  enlarged,  but  usually  is  not  tender. 

The  diagnosis  should  be  made  from  the  age  of  the  patient,  the  history 
of  antecedent  gastro-intestinal  disturbance,  the  mildness  of  the  attack, 
and  the  usually  mild  course  which  the  disease  pursues.  Jaundice  in 
middle  life  or  in  the  aged  is  generally  due  to  gall-stone  disease,  pancrea- 
titis, or  malignacy.  Pain  is  more  marked  in  these  latter  conditions, 
and  usually  is  remittent  in  type;  the  jaundice  varies  in  intensity  unless 
there  is  obstruction  of  the  common  duct;  and  periodic  attacks  of  chills 
and  fever  are  much  more  common  than  in  catarrhal  jaundice. 

The  prognosis  is  good.  Most  cases  of  acute  catarrhal  cholangeitis 
are  prolonged  over  a  period  of  from  three  to  four  weeks,  the  patient 
ultimately  making  a  complete  and  permanent  recovery. 

The  treatment  is  purely  medical,  being  directed  to  the  condition  of 
the  gastro-intestinal  tract.  Disappearance  of  the  jaundice  indicates 
return  of  the  bile-passages  to  normal. 

Chronic  catarrhal  cholangeitis  results  from  mild  infection  of  the 
bile-tract,  or  from  repeated  attacks  of  acute  infection.  It  is  most 
commonly  associated  with  cholelithiasis  (see  page  460)  although  it  may 
occur  as  an  independent  afl'ection. 


PATHOGENESIS    OF    CHOLANGEITIS  447 

In  chronic  catarrhal  cholangeitis  there  is  edema  and  swelling  of  the 
mucous  membrane  with  increased  secretion  of  mucus.  New  fibrous 
connective  tissue  may  be  formed  in  the  walls  of  the  ducts,  especially 
in  those  that  are  extrahepatic,  as  the  result  of  round-cell  infiltration. 
The  walls  usually  are  thicker  than  normal.  In  cases  of  partial  or 
complete  obliteration  of  the  lumen,  the  ducts  above  the  obstruction 
become  markedly  dilated. 

The  symptoms  are  essentially  those  of  recurring  or  relapsing 
jaundice  and  resemble  those  of  acute  catarrhal  jaundice  extended 
over  a  greater  period  of  time.  If  the  obstruction  of  the  common 
duct  is  not  complete,  and  if  there  is  no  ascending  infection  of  the 
bile-passages,  the  disease  runs  a  mild  course  with  remissions  in  the 
intensity  of  the  jaundice.  There  usually  is  no  enlargement  of  the  liver 
or  spleen. 

It  is  almost  impossible  to  make  a  correct  differential  diagnosis  in  all 
cases.  The  conditions  most  frequently  simulating  chronic  cholan- 
geitis are  calculous  obstruction  of  the  common  duct,  pancreatitis  with 
obstruction  of  the  bile-passages,  or  malignancy;  and  these  often  are  the 
cause  or  the  remote  result  of  the  biUary  infection.  In  cases  where  the 
condition  appears  to  be  a  continuation  of  a  simple  catarrhal  jaundice, 
the  diagnosis  may  be  made,  but  with  only  a  fair  degree  of  certainty  on 
account  of  the  probability  that  the  persistence  of  symptoms  is  due  to  a 
stone  in  the  common  duct. 

The  prognosis  is  modified  by  the  associated  lesions. 
The  treatment  is  the  same  as  that  in  acute  catarrhal  jaundice,  except 
in  prolonged  cases  when  the  bile-passages  should  be  explored  and 
drained.  Operation  is  indicated  on  account  of  the  impossibiUty  in 
many  cases  of  excluding  gall-stone  obstruction.  The  operation  of 
choice  is  a  cholecystomy. 

Suppurative  Cholangeitis. — This  rarely  is  dissociated  from  ante- 
cedent lesions  of  the  bihary  tract,  the  most  common  of  which  are  gall- 
stones and  tumors  causing  obstruction  of  the  ducts.  Any  condition 
which  interferes  with  the  normal  flow  of  bile  reduces  the  resistance  of 
the  ducts  and  makes  them  more  susceptible  to  infection.  The  active 
etiological  factor  is  always  bacterial  life  (page  416).  The  result  of  the 
infection  generally  is  widespread,  although  in  a  few  instances  it  may 
be  Umited  to  the  ducts  themselves.  As  a  result  of  the  obstruction  be- 
low, there  is  a  dilatation  of  the  ducts,  which  usually  are  filled  with  bile- 
stained  purulent  material.  The  mucous  membrane  is  congested  and 
edematous;  the  walls  of  the  ducts  are  infiltrated,  softened,  and  much 
thickened.     On  the  surface  of  the  mucous  membrane   may   be  seen 


448  SURGERY    UF    THE    GALL-BL.\DDER   AXD   BILE-DUCTS 

points  of  ulceration.  The  liver  usually  is  enlarged  and  softened,  and 
often  is  the  seat  of  abscesses  which  usually  are  found  near  the  ends  of 
the  radicles  of  the  hepatic  ducts  and  vary  considerably  in  number  and 
size  (suppurative  hepatitis,  page  450).  In  some  instances  the  outward 
pressure  of  the  collections  of  pus  found  in  the  substance  of  the  organ 
renders  the  surface  of  the  liver  irregular.  In  advanced  cases  the  abscess 
or  abscesses  reach  the  surface  and  cause  infection  of  the  serous  covering 
with  a  resulting  perihepatitis,  or  peritonitis.  Involvement  of  the  pleura 
and  lungs  sometimes  follows,  with  or  without  the  development  of  a 
subphrenic  abscess. 

The  onset  often  is  insidious,  and  the  symptoms  may  not  even  suggest 
the  serious  underlying  condition.  There  is  generally  a  history  of  an 
•  antecedent  infection  either  of  the  biliary  passages  (cholelithiasis, 
chronic  cholangeitis) ,  or  of  the  general  system,  such  as  typhoid  fever, 
pneumonia,  etc.  In  those  cases  where  there  has  been  jaundice,  serious 
infection  of  the  biliary  passages  is  announced  by  chills,  fever,  and  sweats, 
which  may  be  very  severe.  Generally  there  is  loss  of  appetite,  nausea 
and  vomiting,  and  progressive  emaciation.  Jaundice  is  present  in  the 
majority  of  cases,  but  may  be  entirely  absent  where  no  complicating 
lesions  exist. 

Pain  of  a  dull  aching  character  almost  always  is  present.  Sharp 
pain,  severe  in  character,  is  present  in  those  cases  where  there  is  an 
associated  cholecystitis,  cholelithiasis,  obstruction  of  neoplasm,  etc. 
The  liver,  spleen,  and  gall-bladder  usually  are  enlarged,  and  there  is 
tenderness  of  the  liver  and  over  the  gall-bladder  region. 

Examination  of  the  blood  shows  leukocytosis  with  marked  increase 
in  the  polynuclear  cells.  The  increase  in  the  leukocytes  often  varies 
considerably  during  the  course  of  the  disease,  being  greater  during  and 
after  the  chills  and  fever. 

Extension  of  the  process  causes  involvement  of  the  surround- 
ing structures;  pleurisy,  pericholecystitis,  multiple  abscesses  of  the 
liver,  etc.,  are  among  the  usual  complications.  The  symptoms  of 
cholangeitis  then  are  more  or  less  hidden  by  the  more  severe  symptoms 
of  the  complicating  condition. 

A  diagnosis  of  suppurative  cholangeitis  may  be  made  safely  in 
those  cases  where  chills,  fever,  sweats,  jaundice,  enlargement  of  the 
liver,  gall-bladder  and  spleen,  and  a  high  polynuclear  leukocytosis 
are  found,  in  connection  with  some  antecedent  disease  of  the  biliary 
tract.  Suppurative  cholangeitis  may  be  difTerentiated  from  tropical 
abscess  of  the  liver  by  the  history  of  dysentery  in  the  latter  affection. 
In  malaria  the  chills  and  fever  are  of  more  regular  periodicity  and 


PATHOGENESIS    OF    CHOLECYSTITIS  449 

blood  examination  should  show  the  presence  of  the  plasmodium  and  the 
absence  of  a  leukocytosis. 

The  progiwsis  in  suppurative  cholangeitis  is  greatly  modified 
by  the  treatment  instituted,  unless  nature  anticipates  the  surgeon  and 
drains  the  bile-ducts  through  a  fistulous  opening  between  the  gall- 
bladder or  common  duct  and  some  viscus  of  the  abdomen  or  thorax. 
Without  drainage  of  the  bile-ducts  the  prognosis  is  very  unfavorable. 

The  trcatvient  should  be  prophylactic  by  treating  carefully  and 
persistently  any  condition  of  the  gall-bladder  or  biliary  passages  that 
might  allow  a  subsequent  virulent  infection  of  the  biliary  tract.  Gall- 
stones should  be  removed  whenever  the  fact  of  their  presence  has  been 
established  (page  495).  After  the  onset  of  suppurative  cholangeitis, 
the  biliary  tract  should  be  drained  by  means  of  a  cholecystostomy  or 
a  choledochostomy  (Chapter  XXIV). 

Immediate  operation  ofters  the  best  prognosis  in  cases  of  acute 
obstruction  of  the  common  duct  from  suppurative  cholangeitis,  as  it 
does  in  the  same  condition  produced  by  impaction  of  a  calculus.  By 
this  means  further  infection  of  the  liver  is  prevented,  and  jaundice  is 
arrested  before  it  becomes  so  profound  as  to  cause  deterioration  of  the 
blood. 

Cholecystitis. — Stagnation  of  bile  in  the  gall-1:)Iadder  is  the  main 
predisposing  cause  of  infection.  Hence  the  stagnant  gall-bladder 
may  assume  almost  the  importance  of  a  clinical  entity.  Owing  to  the 
obstruction  to  the  discharge  of  the  bile  from  the  gall-bladder  its  muscu- 
lar tunic  hypertrophies,  the  mucosa  becomes  somewhat  thickened,  and 
there  is  in  the  submucous,  muscular  and  subserous  coat  a  moderate 
lymphocytic  infiltration.  According  to  Aschoff  and  Bacmeister 
(1909),  this  infiltration  is  not  an  evidence  of  infection  but  is  due  to 
increased  absorption  from  stasis.  The  stagnant  gall-bladder  may  or 
may  not  contain  a  calculus;  usually  a  soUtary  stone  is  present,  of  pure 
cholesterin,  formed  of  radially  disposed  crystals.  The  stagnant  gall- 
bladder is  filled  with  thick,  viscid,  non-labile  bile,  which  is  very  dark 
olive  green,  sometimes  nearly  black  in  color. 

The  lesions  found  in  cholecystitis  vary  from  a  very  mild  catarrhal 
involvement  to  th&*most  virulent  phlegmonous  or  gangrenous  type. 
The  various  degrees  of  inflammation  may  be  classified  as  catarrhal, 
suppurative,  phlegmonous,  and  gangrenous,  the  result  of  the  infection 
varying  with  the  virulence  rather  than  with  the  variety  of  the  invading 
bacteria.  It  was  suggested  by  Kelly,  however,  that  "  the  milder  ca- 
tarrhal lesions  are  most  commonly  due  to  the  typhoid  bacillus  and  the 
colon  bacillus,  and  the  suppurative  lesions  to  the  pyogenic  cocci." 


4SO  SURGERY   OF   THE   GALL-BLADDER   AND   BILE-DUCTS 

In  acute  catarrhal  cholecystitis  the  mucous  membrane  is  edematous 
and  swollen,  especially  in  the  region  of  the  neck  of  the  gall-bladder; 
and  the  mucous  membrane  of  the  cystic  duct  is  involved  to  a  greater  or 
less  degree,  with  consequent  narrowing  of  the  lumen  of  that  channel. 
The  walls  of  the  gall-bladder  are  thickened  and  edematous  and  disten- 
tion by  retained  material  renders  them  tense.  The  thickening  is  due, 
according  to  Aschotf  and  Bacmeister,  chiefly  to  inflammation  of  the 
subserous  tissues  of  the  gall-bladder.  The  contents  of  the  gall-bladder 
usually  consist  of  bile  which  is  thick  and  tarry,  or  of  serous  fluid  which 
is  bile  stained.  This  acute  inflammation  may  subside  quickly  with 
drainage  through  the  cystic  duct,  in  which  instance  all  symptoms  will 
disappear  very  rapidly.  In  other  cases  the  inflammatory  process 
continues,  producing  first  the  suppurative  and  later  the  phlegmonous 
forms  of  cholecystitis.  Sometimes  as  the  acute  process  subsides,  a 
chronic  catarrhal  inflammation  takes  its  place,  often  with  the  formation 
of  gall-stones;  or  acute  exacerbations  may  occur  which  finally  may  result 
in  gradual  obliteration  of  the  cystic  duct  and  hydrops  of  the  gall- 
bladder. 

Hydrops  of  the  gall-bladder  {hydrops  vesica  jellea)  may  be  transi- 
tory or  permanent.  As  pointed  out  by  Kehr  (igci),  acute  infec- 
tion of  the  gall-bladder  and  cystic 
duct  of  a  mild  character  usually  is 
accompanied  by  hydrops.  Upon 
the  subsidence  of  the  inflamma- 
tion, the  cystic  duct  recovers  its 
function,  drainage  of  the  gall- 
bladder occurs  and  the  hydrops  dis- 
appears. In  these  cases  there  is  an 
edema  of  the  mucous  membrane  of 
the  cystic  duct,  the  valves  of  Heister 
Fig.  137.— Hvdrops  of  the  Gall-bladder,  formed  by  the  Convolutions  of  the 

G^^manf  ntpitll*"' "-'"''"'" ''°''""''  ^^cous  membrane  being  so  swollen 

that  obstruction  results.  With  in- 
creased inflammation  there  may  be  superficial  ulceration,  and  as  a 
result  of  the  cicatricial  contraction  of  the  walls  of  the  duct,  the  lumen 
may  be  encroached  upon  to  such  an  extent  that  there  may  be  complete 
occlusion,  with  permanent  hydrops.  1 

The  experimental  work  of  Segre  (1906)  proved  that  very  marked 
changes  occur  in  the  walls  of  the  gall-bladder  from  obstruction  of 
the  cystic  duct.  There  is  first  a  degeneration  of  the  epithelium; 
this  is  followed  by  degeneration  of  the  muscular  layer;  finally,  all 


PATHOGENESIS    OF   EMPYEMA    OF    THE    GALL-BLADDER  45 1 

the  layers  become  transformed  into  connective  tissue.  When  stenosis 
of  the  duct  is  incomplete  the  muscular  coat  hypertrophies;  in  complete 
occlusion  it  atrophies  and  degenerates,  so  that  the  gall-bladder  walls 
may  become  very  thin,  even  translucent,  and  having  the  appearance 
of  parchment. 

The  contents  of  the  gall-bladder  usually  consist  of  a  clear  mucoid 
fluid,  the  secretion  of  the  mucous  membrane. 

The  size  of  the  dropsical  gall-bladder  depends  to  a  great  extent 
upon  the  result  of  previous  infections  of  this  viscus  and  the  presence 
or  absence  of  pericholecystic  adhesions  from  a  prior  inflammation. 
When  the  gall-bladder  walls  have  not  undergone  cicatricial  contraction 
from  previous  inflammatory  attacks  and  when  not  bound  down  by 
surrounding  adhesions,  the  gall-bladder  may  distend  until  it  reaches 
the  brim  of  the  pelvis.  If  adherent  there  will  be  less  chance  of  expan- 
sion; indeed  it  must  not  be  forgotten  that  in  addition  to  the  secretion  of 
the  mucus,  with  which  a  dropsical  gall-bladder  is  filled,  there  may  also 
be  a  certain  amount  of  absorption  going  on  in  the  gall-bladder,  and  that 
if  the  processes  of  secretion  and  absorption  are  nearly  equally  balanced 
the  gall-bladder  may  not  become  distended. 

A  dropsical  gall-bladder  is  a  constant  menace  to  the  patient,  as  it 
may  become  infected,  resulting  in  secondary  empyema  of  the  gall- 
bladder; while  if  of  large  size  it  is  exposed  to  external  injury. 

Suppurative  cholecystitis,  or  empyema  of  the  gall-bladder,  may 
result  from  a  pre-existing  hydrops  vesica  fellea;  usually,  however,  it  arises 
as  a  consequence  of  a  virulent  infection  in  a  gall-bladder  which  pre- 
viously had  been  fairly  healthy,  forming  a  more  advanced  stage  of  the 
so-called  acute  catarrhal  cholecystitis  already  described.  The  condi- 
tion is  comparable  to  a  suppurative  appendicitis;  the  mucous  membrane 
is  much  congested  and  edematous,  and  may  be  ulcerated;  there  are  min- 
ute miliary  abscesses  in  the  submucous,  muscular  and  subserous  coats; 
the  cystic  duct  becomes  quickly  occluded;  and  distention  of  the  gall- 
bladder ensues.  G.  G.  Ross  operated  upon  a  patient  in  the  Lankenau 
(formerly  German)  Hospital,  in  whom  the  distended  gall-bladder,  full 
of  pus,  reached  to  the  brim  of  the  pelvis.  The  condition  had  been 
mistaken  for  an  ovarian  cyst.  Such  extreme  degree  of  distention  is 
very  rare.  E.  M.  Foote  (1910)  collected  five  cases  where  the  gall- 
bladder filled  almost  the  entire  abdominal  cavity  (Terrier,  Tait, 
Gersuny,  Erdmann,  and  Collinson). 

As  the  pressure  increases  the  pus  seeks  an  exit  for  itself  through 
the  cystic  duct;  occasionally  it  is  discharged  in  this  way.  Usually, 
however,  unless  relieved  by  operation,  the  condition  of  the  walls  of 


452  SURGERY    OF    THE    GALL-BLADDER    AND    BILE-DUCTS 

the  gall-bladder  is  such  that  perforation  takes  place,  with  or  without 
the  previous  formation  of  peiicholecystic  adhesions,  just  as  in  the 
phlegmonous  and  gangrenous  types  of  cholecystitis  presently  to  be 
described.  Very  rarely  the  inflammation  subsides,  the  micro-organisms 
lose  their  virulence  and  die.  and  the  empyema  is  converted  into  a  hydrops 
with  sterile  or  very  slightly  infectious  contents. 

Pericholecystitis  most  frecjuently  is  caused  by  suppurative  cholecys- 
titis.'  As  the  purulent  infiltration  spreads  through  the  walls  of  the 
gall-bladder,  localized  peritonitis  occurs,  usually  as  the  result  of  perfora- 
tion of  miliary  abscesses  in  the  subserous  coat.  The  gall-bladder 
becomes  adherent  to  the  colon,  duodenum,  stomach,  omentum,  or 
even  to  the  small  intestines;  and  occasionally  suppurative  perichole- 
cystitis is  found  without  any  macroscopic  perforation  of  the  gall- 
bladder. These  pericholecystic  adhesions  serve  as  a  protection  against 
the  development  of  diffuse  peritonitis;  but  as  the  acute  inflammation 
subsides  the  adhesions  contract,  cause  distortion  of  the  gall-bladder 
and  bile-ducts,  obstruction  of  the  pylorus  or  colon,  and  thus  predispose 
to  recurrent  attacks  of  cholecystitis,  to  intestinal  obstructions,  etc. 

Biliary  Peritonitis  Without  Perforation  of  the  Bile- passages. — This 
is  a  condition  occasionally  seen,  and  requiring  a  few  words  of  explana- 
tion. A  bile-stained  peritoneal  effusion  is  found,  and  yet  no  macro- 
scopic evidence  of  a  perforation  can  be  discovered  anywhere  in  the 
bile-tract.  G.  G.  Davis  called  attention  to  the  condition  in  1907, 
reporting  two  cases  of  bile-stained  peritoneal  efifusion  without  apparent 
lesions  of  the  biliary  tract.  In  one  of  these  cases  chemical  examination 
failed  to  give  any  evidence  of  the  presence  of  bile  in  the  bile-colored 
peritoneal  exudate,  though  the  gauze  sponges  were  stained  character- 
istically yellow,  Clairmont  and  Haberer  reported  a  case  with  similar 
effusion,  but  with  a  stone  in  the  common  duct,  yet  no  perforation; 
and  Schievelbein  has  reported  another  case,  in  which  operation  was 
done  by  Ritter.  In  none  of  these  cases,  however,  was  the  fluid  exam- 
ined for  bile.  Wolft'  has  reported  three  more  cases,  and  the  whole 
subject  has  been  reviewed  by  Johansson  (1912)  and  Buchanan  (1917). 

Clairmont  and  Haberer  (1910)  produced  the  condition  experimen- 
ally  in  a  few  dogs  out  of  a  large  number  in  which  they  caused  obstruc- 
tion of  the  common  duct  for  another  purpose:  in  a  few  days  these 
dogs  had  biliary  peritonitis;  the  abdominal  wall  was  markedly  icteric, 
while  the  skin  and  the  rest  of  the  muscular  tissues  showed  only  slight 
jaundice. 

'  It  is  desirable  to  distinguish  between  pcricltolccyslilis,  an  active  inflammatory  state, 
and  pericholecystic  adhesions  the  result  of  previous  inllammation. 


PATHOGENESIS    OF    GANGRENOUS    CHOLECYSTITIS  453 

Schievelbein  (1910)  claimed  that  this  biliary  effusion  is  a  tiltrate 
through  the  walls  of  a  nearly  normal  gall-bladder.  In  a  gall-bladder 
altered  by  disease  the  walls  become  impermeable  for  such  filtration. 
He  thinks  the  subserous  position  of  the  canals  known  by  Luschka's 
name  ("Luschka's  Gange")  has  much  influence  in  permitting  this  filtra- 
tion. According  to  Johansson,  these  canals  exist  only  in  about  io  per 
cent,  of  gall-bladders.  It  thus  appears  that  only  when  the  two  rare 
factors  coexist  (presence  of  Luschka's  Gange,  and  acute  obstruction  of 
an  almost  normal  gall-bladder)  can  biliary  peritonitis  occur  without 
perforation  of  the  bile-tract.  That  the  effusion  in  some  cases  at  least 
really  is  biliary  is  demonstrated  by  the  cases  of  Schievelbein,  and  the 
similar  case  mentioned  by  Gibbon  (1913),  in  both  of  which  the  bile- 
stained  fluid  oozed  through  the  walls  of  the  gall-bladder  under  the 
operator's  eyes. 

Buchanan,  in  his  admirable  study  of  the  subject  (191 7),  concludes 
that  with  our  present  knowledge  it  is  not  possible  to  classify  all  cases 
of  this  nature  in  the  same  category;  many  of  them  he  believes  are  due  to 
retroperitoneal  ruptures  or  perforations  of  the  bile  passages,  the  effused 
bile  leaking  into  the  peritoneum  some  distance  away  from  the  actual 
perforation  which  thus  is  readily  overlooked. 

The  treatment  consists  in  evacuating  the  effused  bile  by  moppirag, 
after  laparotomy,  and  in  drainage  of  the  pelvis;  where  not  contra- 
indicated,  the  common  bile  duct  itself  should  also  be  drained  as  advised 
by  Buchanan. 

In  phlegmonous  chlecystitis  there  is  a  still  more  virulent  infection. 
The  mucous  membrane  becomes  markedly  edematous  and  swollen, 
the  submucous,  muscular,  and  subserous  coats  become  riddled  with 
miliary  abscesses,  resulting  in  separation  of  the  various  coats  from 
each  other  and  sometimes  in  the  separation  of  the  entire  mucous 
membrane  as  a  slough.  The  walls  of  the  gall-bladder  are  dark  in 
color,  rigid,  but  friable;  the  contents  are  bloody  pus,  and  sloughs. 
Usually  the  process  is  so  acute  that  no  pericholecystic  adhesions  are 
formed.  The  necrosis  extends  through  the  serous  coat,  a  layer  of 
lymph  alone  separating  the  slough  from  the  peritoneum;  when  this 
gives  way  (perforation)  the  highly  infectious  contents  are  poured  out 
into  the  unprotected  peritoneal  cavity,  and  diffuse  peritonitis  ensues. 

Gangrenous  cholecystitis  results  from  the  most  virulent  infections, 
or  from  thrombosis  of  the  nutrient  artery.  The  lesions  are  practically 
the  same  as  those  of  the  phlegmonous  type  except  that  the  necrosis 
or  gangrene  involves  a  considerable  portion  of  the  viscus,  instead  of 
being  localized  to  the  area  of  perforation.     Owing  to  the  poorer  blood 


454  SURGERY    OF    THE    GALL-BLADDER    AND    BILE-DUCTS 

supply  at  the  fundus,  the  gangrenous  process  usually  starts  there  and 
extends  toward  the  cystic  duct.  Many  so-called  cases  of  gangrenous 
cholecystitis,  really  should  be  termed  ulcerative  cholecystitis,  a  con- 
dition which  usually  forms  a  part  of  suppurative  or  phlegmonous 
inflammation,  as  already  described. 

Volvulus  of  the  gall-bladder  is  rare.  The  presence  of  a  mesentery 
to  the  gall-bladder,  resulting  in  the  condition  known  as  wandering 
gall-bladder  (page  444).  is  a  predisposing  cause.  The  existence  of  a 
volvulus  seldom  is  recognized  during  life;  if  any  localizing  symptoms 
are  present  they  usually  are  misunderstood.  Kiibig  (1912)  records  one 
case  found  at  autopsy,  and  refers  to  three  other  cases  reported  by 
Miisham,  Mayer,  and  Fischer,  in  which  the  diagnoses  made  had  been 
appendicitis,  hydronephrosis,  and  gall-stones.  All  these  patients 
were  old,  and  three  of  them  were  women.  In  many  cases  gangrene 
of  the  gall-bladder  results  from  interruption  of  the  circulation.  One 
case  of  torsion  of  the  gall-bladder  has  been  encountered  at  autopsy 
at  the  Lankenau  Hospital: 

Postmortem  Record:  J.  !Mc^L,  male,  death  from  endocarditis.  The  gall-bladder 
was  distended,  its  walls  thickened  and  adherent  to  the  liver.  The  cystic  duct  was 
obstructed  by  torsion.  There  was  no  stricture  of  the  duct.  No  calculi  were 
present. 

Non-calculous  cholecystitis  as  a  pathological  entity  is  a  con- 
dition found  in  about  15  to  20  per  cent,  of  all  diseases  of  the  bihary 
tract.  In  a  series  of  476  patients  with  diseases  of  the  biliary  tract 
operated  upon  by  the  senior  author,  gall-stones  were  absent  in  18.3  per 
cent.  Riedel  found  no  stones  in  eleven  of  sixty-live  patients  operated 
upon  under  the  diagnosis  of  cholehthiasis. 

The  etiological  and  pathological  factors  in  cholecystitis  have 
been  considered  at  page  418. 

The  symptomatology  of  cholecystitis  is  most  ^'ariable.  In  many 
instances  the  attack  is  so  fleeting  that  the  patient  does  not  remember 
it  and  it  can  be  recalled  to  his  mind  only  after  verj-  close  questioning. 
In  other  instances  the  onset  of  the  inflammation  is  sudden  and  the 
symptoms  alarming.  The  wide  variance  between  these  two  conditions 
is  due  entirely  to  the  virulence  of  the  invading  micro-organism  and  the 
presence  or  absence  of  an  infectious  disease  such  as  tA*phoid  fever 
(page  430). 

The  pai7i  maj'  be  dull  and  aching,  severe  and  continuous  with 
acute  exacerbations,  or  paroxysmal,  being  then  identical  with  the 
so-called  gall-stone  colic.     Solicri  (iqii)  has  reported  the  case  of  a 


SYMPTOMS    OF    ACUTE    CHOLECYSTITIS  455 

patient  (who  had  recently  had  typhoid  fever)  whose  biliary  colic 
was  caused  by  hemorrhages  into  the  gall-bladder;  and  a  patient  in  whom 
intracystic  hemorrhage  seems  to  have  been  responsible  for  attacks 
of  bihary  colic,  was  under  the  care  of  the  junior  author  at  the  Episcopal 
Hospital  in  191 1.  This  patient's  history  was  recorded  in  the  first 
edition  of  this  book. 

The  initial  pain  usually  is  in  the  epigastrium,  or  it  may  be  diffuse, 
gradually  becoming  localized  in  the  right  hypochondrium.  The  pain 
may  remain  localized  or  may  be  referred  to  the  right  shoulder,  the 
right  shoulder-blade,  or  to  the  right  iliac  fossa,  in  the  latter  instance 
simulating  the  pain  of  appendicitis  with  which  condition  cholecystitis 
may  be  associated. 

Nausea  and  vomiting  vary  greatly.  If  the  onset  is  violent  there 
will  be  marked  nausea  and  vomiting  accompanied  by  great  prostration. 
In  mild  cases  there  may  be  slight  nausea  and  no  vomiting.  When 
the  vomiting  persists,  the  inflammation  of  the  gall-bladder,  in  most 
instances,  has  extended  beyond  the  confines  of  that  viscus  with  result- 
ing pericholecystitis  or  peritonitis. 

Fever  usually  is  present  but  varies  in  degree  and  persistency.  When 
the  infection  of  the  gall-bladder  complicates  some  other  disease,  such 
as  typhoid  fever,  the  temperature  may  be  attributed  to  the  under- 
lying disease;  if  it  arises  during  the  convalescence  from  typhoid  fever  the 
temperature  may  be  high  from  the  effects  of  the  cholecystitis  alone. 

Muscular  rigidity  always  is  present,  in  some  cases  being  of  such 
a  character  that  it  will  simulate  a  tumor.  Careful  palpation  some- 
times reveals  the  true  gall-bladder  tumor  lying  beneath  the  rigid 
muscle. 

Tenderness  usually  is  marked,  and  especially  so  in  the  presence 
of  pericholecystitis.  The  tenderness  in  the  beginning  of  the  affection 
may  be  more  or  less  diffuse,  although  it  will  almost  invariably  become 
localized  over  the  gall-bladder. 

The  gall-bladder  will  become  enlarged,  the  size  of  the  viscus  varying 
greatly  in  different  cases.  In  some  instances  it  is  so  large  that  it  is 
distinctly  visible.  It  is  uniformly  pear-shaped,  and  moves  with 
respiration.  It  may  be  displaced  by  manipulation  in  those  cases 
where  there  are  no  adhesions,  but  always  returns  to  its  former  position, 
thus  differing  from  a  movable  kidney  or  a  pyloric  tumor.  As  the  gall- 
bladder increases  in  size,  it  usually  extends  downward  and  inward 
toward  the  umbilicus;  rarely  it  may  be  found  in  the  right  flank,  in  the 
right  iliac  fossa,  or  even  extending  to  the  brim  of  the  pelvis.  The 
subsequent   history   of   the   enlarged   gall-bladder   will   depend   upon 


456  SURGERY    OF    THE    GALL-BLADDER    AND    BILE-DfCTS 

the  condition  of  tlie  lumen  of  the  cystic  duct  and  the  presence  or 
absence  of  virulent  infection.  In  the  majority  of  cases,  the  cystic 
duct  becomes  patulous  with  the  subsidence  of  the  inflammation  and 
the  gall-bladder  drains  itself  through  the  natural  channels;  with 
obstruction  of  the  cystic  duct  persisting,  either  a  hydrops  or  an  empy- 
ema of  the  gall-bladder  will  result. 

Jaundice  is  never  seen  in  uncomplicated  cases  of  cholecystitis.  As 
long  as  the  common  and  hepatic  ducts  remain  patulous,  jaundice 
does  not  occur.  If  the  inflammation  should  involve  either  of  these 
ducts  directly  or  through  adhesions,  jaundice  would  ensue  as  soon  as 
the  lumen  of  the  ducts  became  greatly  lessened. 

The  results  of  acute  cholecystitis  are  many;  most  of  them  are  of 
decided  clinical  importance  as  they  have  a  great  bearing  on  the  subse- 
quent health  and  activity  of  the  patient.  In  a  large  majority  of  the 
cases  the  symptoms  presented  disappear  in  from  four  to  ten  days,  but 
it  is  probable  that  the  gall-bladder  seldom,  if  ever,  returns  to  the  condi- 
tion in  which  it  was  before  the  infection.  A  chronic  inflammation  may 
ensue  (page  459).  A  very  frequent  consequence  of  a  mild,  subsiding 
infection  of  the  gall-bladder  is  the  formation  of  gall-stones  (page  420). 
Sometimes  the  symptoms  that  persist  after  the  subsidence  of  the 
inflammation  are  due  not  only  to  the  condition  of  the  gall-bladder,  but 
to  adhesions  formed  between  that  viscus  and  adjacent  organs,  the 
result  of  a  pericholecystitis  (page  452). 

When  the  infection  is  of  a  very  severe  type,  or  where  it  does  not 
subside  but  rather  becomes  augmented,  possibly  by  added  infection, 
much  more  serious  conditions  of  the  gall-bladder  ensue,  suppurative, 
phlegmonous,  or  gangrenous  cholecystitis.  Of  these  varieties  of  gall- 
bladder disease  the  gangrenous  is  the  most  rare,  while  the  suppurative 
type  is  not  uncommon.  In  most  instances  the  severe  forms  of  infection 
occur  in  connection  with  cholelithiasis.  In  a  series  of  328  operations 
on  the  biliary  tract  by  the  senior  author,  gangrene  of  the  gall-bladder 
was  encountered  only  twice.     Both  patients  recovered. 

The  symptoms  presented  by  these  severe  forms  of  cholecystitis 
are  similar  to  those  of  acute  cholecystitis,  but  greatly  aggravated,  with 
much  more  pronounced  indications  of  involvement  of  the  peritoneum. 
The  pain  and  tenderness  are  more  general,  at  times  extending  over  the 
entire  abdomen.  Nausea  and  vomiting  may  be  persistent,  and  the 
picture  presented  is  one  of  infection  of  the  general  peritoneal  ca\-ity 
rather  than  of  the  gall-bladder.  The  temperature  is  higher,  reaching 
103°  or  io4°F.  The  blood  count  shows  a  decided  increase  of  leuko- 
cytes with  relative  increase  in  the  polynuclear  cells. 


DIAGNOSIS    OF    ACUTE    CHOLECYSTITIS  457 

Perjoration  of  the  gall-bladder  may  cause  a  fistula  between  the  gall- 
bladder and  the  stomach,  duodenum  or  colon;  it  may  open  into  the 
liver  with  the  formation  of  a  liver  abscess;  it  may  perforate  into  a  mass 
of  adhesions  surrounding  the  gall-bladder  with  the  formation  of  a  local 
abscess.  In  such  cases  the  acute  symptoms  are  suddenly  relieved. 
But  in  many  cases  perforation  occurs  into  the  general  peritoneal  cavity, 
and  cause  rapidly  spreading  and  usually  fatal  peritonitis. 

The  diagnosis  of  cholecystitis  usually  is  readily  made.  The  chain  of 
symptoms  presented  in  most  cases,  (nausea  and  vomiting,  pain  and 
tenderness  over  the  gall-bladder  region,  rigid  abdominal  muscles  over 
an  enlarged  and  tender  gall-bladder)  should  lead  to  a  correct  diagnosis. 
The  mild  and  severe  forms  of  cholecystitis  generally  may  be  differenti- 
ated by  the  intensity  of  the  symptoms  presented.  It  is  generally  im- 
possible to  differentiate  between  calculous  and  non-calculous  cholecys- 
titis, especially  when  the  gall-stones  are  confined  to  the  gall-bladder. 
Gall-stones,  as  a  rule,  give  rise  to  no  symptoms  when  in  the  gall-bladder, 
the  phenomena  of  gall-stone  colic  being  due  to  inflammation  consequent 
upon  infection.  Gangrene  or  perforation  in  acute  cholecystitis  cannot 
always  be  recognized  but  may  be  suspected  on  the  occurrence  of  a 
sudden  exacerbation  of  the  pain  and  increase  of  the  general  peritoneal 
symptoms;  and  perforation  especially  may  be  suspected  if  a  gall- 
bladder previously  palpable  suddenly  seems  to  disappear. 

Acute  cholecystitis  must  be  differentiated  from  acute  appendicitis 
although  failure  to  do  this  is  not  uncommon.  The  pain  of  appendicitis 
may  be  in  the  gall-bladder  region,  and  the  pain  of  the  cholecystitis 
may  be  found  in  the  right  iliac  fossa.  Tenderness  from  an  inflamed 
gall-bladder  may  be  elicited  in  the  appendiceal  region.  Both  diseases 
may  be  caused  by  a  common  bacterial  invasion.  In  patients  past 
forty-five  years  of  age  appendicitis  is  comparatively  rare.  The  pain 
of  acute  cholecystitis  is  more  often  limited  to  the  epigastrium  and  the 
right  hypochondrium,  and  that  of  acute  appendicitis  more  often  to  the 
right  iliac  fossa.  Referred  pain  is  not  common  in  appendicitis,  while 
it  often  is  present  in  cholecystitis.  The  initial  pain  in  appendicitis  is 
more  general  than  that  of  cholecystitis.  The  presence  of  a  tumor  which 
moves  with  respiration  is  characteristic  of  cholecystitis.  We  agree  with 
Hotchkiss  (1899)  in  attaching  great  importance  to  lateral  compression 
of  the  lower  ribs  in  developing  pain  in  cholecystitis.  A  careful  study 
on  the  onset  will  be  a  great  help  in  clearing  up  the  diagnosis. 

In  intestinal  obstruction  there  is  a  chain  of  symptoms  similar  to 
those  of  acute  cholecystitis,  pain,  nausea  and  vomiting,  constipa- 
tion and  tympany.     But  in  intestinal  obstruction  there  is  no  rise  of 


4S8  SURGERY    OF    THE    GALL-BLADDER    AND    BILE-DUCTS 

temperature  before  the  onset  of  peritonitis;  while  in  acute  cholecystitis 
elevation  of  the  temperature  is  common.  If  a  gall-bladder  tumor  can 
be  recognized  the  diagnosis  is  clear. 

Acute  pancreatitis  may  give  rise  to  the  same  symptoms  as  a  severe 
infection  of  the  gall-bladder.  In  pancreatitis,  however,  there  generally 
is  much  more  constitutional  disturbance  and  the  patient  appears  to  be 
more  profoundly  ill  than  in  acute  cholecystitis.  The  pain  and  the 
tenderness  in  pancreatitis  more  often  are  in  the  epigastrium.  Tumor  is 
more  commonly  recognized  in  gall-bladder  infection  and  is  located  in 
the  majority  of  the  cases  beneath  the  ninth  costal  margin,  while  that 
of  the  pancreas  usually  is  behind  the  stomach,  near  the  mid-line  or  to 
the  left,  and  usually  not  easily  palpable.  Some  writers  claim  that 
dififerentiation  between  these  two  affections  is  of  academic  interest 
only,  as  the  treatment  they  advocate  for  both  conditions  is  the  same, 
immediate  drainage  of  the  gall-bladder.  We  do  not  agree  with  this 
opinion  in  all  cases,  however,  as  better  results  often  may  be  obtained 
by  proper  treatment  before  operative  measures  are  instituted. 

Prognosis. — The  prognosis  in  the  majority  of  cases  of  acute  chole- 
cystitis is  good,  the  inflammation  subsiding  and  the  gall-bladder 
draining  itself  through  the  cystic  duct.  But  a  gall-bladder  that  has 
been  infected  will  be  the  seat  of  repeated  attacks  of  inflammation  in  a 
majority  of  cases.  In  the  severe  types  of  infection  the  prognosis 
must  always  be  guarded,  and  in  the  gangrenous  or  phlegmonous  type 
it  is  very  grave.  The  sequels  of  the  inflammation  often  are  of  much 
more  importance  than  the  original  attack,  pericholecystic  adhesions 
frequently  causing  great  impairment  of  health  with  marked  suffering; 
while  gall-stone  formation  is  an  exceedingly  frequent  sequel  of  infection 
of  the  biliary  tract.  The  ultimate  prognosis  in  these  cases  is  greatly 
modified  by  the  treatment  instituted;  this  we  believe  should  be  opera- 
tive interference,  the  surgical  procedure  being  modified  by  the  condi- 
tions found. 

Treatment. — The  majority  of  mild  infections  of  the  gall-bladder 
will  subside  under  appropriate  medical  treatment.  This  implies  rest  in 
bed  in  the  semi-sitting  position,  hot  or  cold  applications,  preferably 
the  latter,  to  the  upper  right  quadrant  of  the  abdomen,  absolutely 
nothing  by  mouth  and  fluids  by  proctoclysis.  Before  starting  procto- 
clysis give  a  cleansing  enema;  this  can  be  repeated  each  day  if  the 
patient  suffers  with  accumulation  of  gas.  To  the  enema  may  be  added 
asafetida  or  glycerine  and  turpentine.  When  all  acute  symptoms  have 
been  absent  for  thirty-six  or  forty-eight  hours  sodium  phosphate 
in  hot  water  may  be  given  by  mouth.     The  treatment  recently  advo- 


TREATMENT    OF    ACUTE    CHOLECYSTITIS  459 

cated  by  Lyon  (1920),  consisting  in  the  local  application  of  magnesium 
sulphate  to  the  duodenal  mucosa  by  means  of  the  duodenal  tube,  so  as 
to  cause  relaxation  of  the  sphincter  of  Oddi,  can,  so  far  as  we  are  able  to 
see,  have  no  influence  on  the  gall-bladder  and  cystic  duct  when  they 
are  acutely  inflamed. 

The  treatment  outlined  above  is  not  that  usually  instituted  by 
internists,  but  it  is  our  opinion  that  this  is  the  rational  course  to  pursue, 
with  various  modifications,  in  the  early  stages  of  acute  cholecystitis. 
We  know  that  patients  recover  more  rapidly  and  with  less  discomfort, 
if  all  food  is  withheld  for  from  forty-eight  to  seventy-two  hours,  as  above 
stated,  or  until  there  is  restoration  of  peristalsis  and  the  passage  of  gas. 
Repeated  lavage  of  the  stomach  relieves  that  organ  of  any  material 
regurgitated  into  it,  and  checks  the  nausea  and  vomiting.  We  prefer 
ice-cold  applications  to  the  gall-bladder  region,  as  these  allay  pain  and 
inflammation  more  readily  than  apphcations  of  heat.  After  recovery 
from  the  attack,  treatment  at  some  of  the  noted  Springs,  such  as  Rich- 
field, Mt.  Clemens  or  Saratoga,  may  be  of  value,  if  the  case  is  one 
of  non-calculous  cholcystitis. 

Operative  procedures  should  be  instituted  in  all  recurrent  cases  of 
mild  inflammation  of  the  gall-bladder.  A  second  attack  of  non-calcu- 
lous cholecystitis  is  an  indication  that  the  gall-bladder  is  the  seat  of  a 
chronic  infection  which  is  prone  to  flare  up  at  any  time  and  result  in 
much  more  severe  consequences.  Acute  cholecystitis  of  a  severe  type 
should  be  operated  upon  as  soon  as  possible,  except  in  the  presence  of 
diffuse  peritonitis,  when  better  results  will  be  obtained  by  the  so-called 
Ochsner  treatment  for  peritonitis. 

The  operation  of  choice  in  non-calculous  cholecystitis  is  simple 
drainage  of  the  gall-bladder.  If  there  is  obstruction  of  the  cystic  duct 
due  to  inflammatory  thickening  of  the  mucous  membrane,  drainage  of 
the  gall-bladder  will  allow  the  inflammation  to  subside  and  will  thus  re- 
store free  communication  between  the  gall-bladder  and  the  common  duct. 

In  the  more  severe  types  of  non-calculous  inflammation,  where 
there  is  evidence  that  the  gall-bladder  will  become  functionless,  or 
where  the  cystic  duct  is  permanently  closed  by  cicatricial  contraction, 
or  where  there  is  decided  enlargement  of  the  lymph-node  at  the  junction 
of  the  supra-  and  retroduodenal  portions  of  the  common  duct,  indicating 
infection  of  the  chain  of  peri-pancreatic  lymphatics,  cholecystectomy 
should  be  performed. 

Chronic  cholecystitis  may  be  the  end  result  of  acute  inflammation, 
or  it  may  be  due  to  an  inflammation  of  the  chronic  type  from  the 


460  SURGERY    OF    THE    GALL-BLADDER    AND    BILE-DUCTS 

beginning.  Non-calcuous  chronic  cholecystitis  is  not  so  common  as  the 
calculous  form  of  the  disease,  gall-stones  being  associated  and  sustaining 
the  inflammation  in  a  large  majority  of  cases.  The  etiology  of  this 
condition  is  that  of  the  acute  inflammation,  "the  chronicity,"  as  stated 
by  Kelly,  "being  a  manifestation  of  lingering  infection  (which  is  com- 
mon), or  the  consequence  of  very  low-grade  infection  with  almost  but 
not  quite  sufficient  biliary  drainage." 

In  non-calculous  chronic  cholecystitis,  the  lesions  may  be  confined 
entirely  to  the  mucosa,  with  congestion,  swelling,  desquamation  and  a 
greater  amount  of  mucus  than  normal;  or  there  may  be  infiltration  of 
the  walls  of  the  gall-bladder,  with  areas  of  erosion.  When  the  tips  of 
the  villi  which  have  undergone  desquamation  become  stained  with  bile, 
what  has  been  called  the  "strawberry  gall-bladder"  is  present  (p. 
466) ;  the  same  condition  may  be  due  to  deposition  of  lipoids  and 
cholesterin  in  the  mucosa  and  submucosa  (Reiman,  iqig).  In  other 
cases  the  walls  of  the  gall-bladder  are  distended  and  thin  and  the  gall- 
bladder is  filled  with  thick  mucus  and  bile.  In  long-standing  cases 
there  usually  is  contraction  of  the  organ;  associated  with  these  cases 
very  frequently  is  a  mass  of  adhesions  surrounding  and  pressing  upon 
the  gall-bladder. 

Chronic  cholecystitis  is  almost  always  present  in  patients  with 
biliary  calculi  which  give  rise  to  symptoms.  We  believe  that  the 
symptoms  are  caused  by  the  inflammation  and  not  by  the  gall-stones 
themselves.  When  gall-stones  are  present  the  changes  in  the  walls  of 
the  gall-bladder  usually  are  more  marked,  the  inflammation  invading 
the  deeper  layers  of  the  walls  and  causing  hyperplastic  and  proliferative 
changes.  This  condition  is  considered  by  Kelly  as  the  beginning  of 
carcinomatous  degeneration. 

The  symptoms  presented  by  chronic  cholecystitis,  whether  calculous 
or  non-calculous,  are  essentially  those  of  cholelithiasis  (page  481),  and  it 
is  impossible  to  determine  from  symptoms  alone  whether  or  not  calculi 
are  present.  Repeated  attacks  of  biliary  colic  followed  by  icterus, 
might  lead  to  a  correct  diagnosis  of  cholelithiasis.  In  the  patients  of 
the  senior  author  at  the  Lankenau  Hospital,  colicky  pains  have  been 
noted  in  70.6  per  cent,  of  the  cases  of  non-calculous  chronic  cholecystitis, 
while  jaundice  has  been  present  in  35.3  per  cent. 

The  prognosis  and  treatment  are  those  of  cholelithiasis  (page  495). 

ClIOLELITHLASIS 

The  etiology  of  gall-stone  formation,  the  character  and  composition 
of* gall-stones,  etc.,  have  been  considered  in  the  previous  chapter  (page 
419). 


PATHOLOGY  OF  CHOLELITHIASIS  46 1 

Pathology. — In  studying  the  pathology  of  cholelithiasis,  it  prob- 
ably would  be  more  correct  to  classify  the  various  lesions  as  complica- 
tions of  gall-stones,  rather  than  as  changes  due  to  the  mere  presence 
of  the  calcuh.  Gall-stones,  in  the  absence  of  an  added  infection,  seldom 
cause  any  serious  pathological  changes;  they  may  remain  indefinitely 
in  the  gall-bladder,  where  they  have  been  formed,  without  giving  rise 
to  any  symptoms  directly  referable  to  the  bihary  tract.  Kehr  (igoi) 
stated  that  almost  every  tenth  adult  has  gall-stones  but  that  only  5 
per  cent,  of  those  having  biliary  calculi  present  signs  or  symptoms  of 
their  presence,  the  remaining  95  per  cent,  having  no  knowledge  of 
their  existence.  The  postmortem  records  of  the  Lankenau  Hospital 
show  the  presence  of  calculi  in  the  gall-bladder  or  ducts  in  over  11  per 
cent,  of  the  autopsies,  the  death  in  each  instance  having  been  due  to 
diseases  other  than  those  of  the  biliary  tract.  Although  these  gall- 
bladder examinations  made  at  autopsy  were  limited  to  524  cases,  yet 
the  findings  support  the  statement  of  Kehr  so  far  as  the  prevalence  of 
biliary  calculi  is  concerned.  The  proportion  of  those  having  gall- 
stones and  not  presenting  any  symptoms  may  be  as  high  as  Kehr  states; 
and  the  presence  of  calcuH  in  the  gall-bladder  may  be  of  no  significance; 
yet  we  believe  that  a  more  careful  study  of  such  patients  would  elicit 
symptoms,  in  the  majority  of  cases,  due  to  the  presence  of  gall-stones 
but  incorrectly  assigned  to  functional  disturbances  of  the  gastro- 
intestinal tract. 

When  the  gall-stones  are  formed  there  are  present  in  the  gall-bladder 
bacteria  of  attenuated  virulence,  and  a  catarrhal  inflammation  of  the 
mucous  membrane.  The  gall-bladder  rids  itself  of  the  catarrhal  in- 
flammation and  bacteria,  and  the  normal  flow  of  bile  becomes  reestab- 
lished in  a  large  proportion  of  cases,  leaving  the  gall-stones  behind  as 
a  record  of  the  acute  process.  In  such  instances  the  stones  may  remain 
in  the  gall-bladder  indefinitely;  and  by  themselves,  unaided,  will  not 
necessarily  cause  any  further  serious  trouble.  The  persisting  lesions 
are  so  slight  that  they  give  rise  to  no  symptoms  or  signs  in  the  gall- 
bladder region;  but  there  are  numerous  instances  where  disorders  of 
digestion  can  be  cured  only  by  the  removal  of  gall-stones,  the  presence 
of  which  has  never  been  suspected  by  the  patient.  We  believe  that  a 
recognition  of  these  cases  will  greatly  decrease  the  estimated  proportion 
of  those  individuals  having  biliary  calculi  but  not  presenting  symptoms 
of  their  presence. 

Calculi  in  any  portion  of  the  biliary  tract  invite  renewed  infection. 
Without  such  infection  they  seldom  give  rise  to  serious  pathological 
lesions,  and  the  gall-bladder  and  ducts  may  remain  for  long  periods  in 


462  SURGERY   OF    THE    GALL-BL.\DDER    AND   BILE-DUCTS 

the  condition  they  were  in  after  the  subsidence  of  the  stone-forming 
bacterial  invasion.  Riedel,  as  quoted  by  Kehr,  was  of  the  opinion  that 
a  "foreign-bod}'  inflammation,"  independent  of  bacterial  invasion, 
may  arise  in  the  gall-bladder  or  ducts  with  the  same  efl'ect  that  would 
result  from  a  "  bacterial  inflammation."  The  "  foreign  body  inflamma- 
tion," possibly,  may  occur;  it  is  more  probable,  however,  that  in  all 
such  instances  a  bacterial  invasion  takes  place  afresh,  being  so  rapid 
in  its  course,  at  times,  that  it  does  not  give  rise  to  anj'  marked  symptoms 
or  pathological  lesions. 

Non-inflammatory  movements  of  the  concretions  within  the  gall- 
bladder may  be  caused,  to  a  very  shght  degree,  by  the  to-and-fro  motion 
of  the  bile.  The  lesions  thus  produced  are  of  Httle  significance,  al- 
though Kehr  claimed  that  "  cancer  of  the  gall-bladder  may  develop 
from  the  irritation  of  the  stones  actually  lying  quiescent  in  the  fundus." 
Stones  may  be  come  dislodged  from  their  resting  place  and  cause  some 
interference  with  the  outflow  of  the  bile  from  the  gall-bladder.  As  a 
rule,  however,  they  do  not  wander;  they  remain  where  they  were 
formed,  until  dislodged  by  contractions  of  the  gall-bladder  incited  by 
inflammatory  irritation,  the  latter  being  the  result  of  the  new  infection 
of  the  viscus  or  of  an  acute  exacerbation  of  an  old  process. 

The  mechanical  action  of  the  gall-stones  after  the  onset  of  active 
inflammation  in  the  bihary  tract  is  that  of  a  foreign  body.  The  con- 
cretions may  remain  quiescent;  they  may  be  forced  into  the  cystic 
duct,  or  through  it  into  the  common  duct,  and  through  the  common  duct 
into  the  intestine.  After  reaching  the  duodenum  they  may  be  expelled 
with  the  feces  or  may  become  so  augmented  by  added  laminations 
that  intestinal  obstruction  will  result.  Occasionally  gall-stones  have 
lodged  in  the  appendix  vermiformis,  as  in  cases  reported  by  Lediard, 
Budd,  Serey,  Rehn,  Treves,  and  Robson;  and  as  in  a  patient  under  the 
care  of  H.  C.  Deaver.  Chemical  study  of  the  concretions  is  requisite 
to  ascertain  their  origin. 

Gall-stones  may  cause  necrosis  of  the  gall-bladder  or  ducts  with  the 
subsequent  perforation  and  expulsion  of  the  stone  into  the  liver  sub- 
stance, into  a  mass  of  adhesions  formed  around  the  gall-bladder,  or  into 
one  of  the  adjacent  hollow  viscera,  such  as  the  stomach,  the  duodenum 
or  the  colon.  If  they  become  lodged  in  the  cystic  duct,  there  will 
result  a  closure  of  that  channel  either  complete  or  partial,  with  simple 
hydrops  or  empyema  of  the  gall-bladder,  depending  upon  the  nature 
and  virulence  of  the  invading  organism.  At  times  the  inflammation 
will  subside  and  the  cystic  duct  remain  partially  patent,  so  that  there  will 
be  a  discharge  of  the  contents  of  the  gall-bladder  and  a  return  to  com- 


PATHOLOGY    OF    CHOLELITHIASIS  463 

paratively  normal  conditions.  The  presence  of  the  stone  in  the  duct 
will  encourage  subsequent  infections,  as  it  will  always  act  as  an  irri- 
tant; it  is  less  apt  to  do  this  if  it  becomes  encysted  by  being  covered  by 
the  swollen  mucous  membrane  or  by  forming  a  pocket  or  diverticulum 
for  itself.  The  effect  of  such  improvement  of  the  stone  is  to  cause  a 
deviation  of  the  channel  and  consequent  interference  with  the  natural 
to-and-fro  motion  of  the  bile. 

The  stone  may  become  lodged  in  the  common  duct  and  may  remain 
there  an  indefinite  period  without  giving  rise  to  any  symptoms.  On 
the  other  hand,  it  may  cause  complete  and  temporary  or  partial  and 
permanent  obstruction  of  the  duct,  with  damming  up  of  the  bile, 
changes  in  the  gall-bladder  and  Hver,  intermittent  icterus,  etc. 

In  a  series  of  549  cases  of  cholelithiasis,  operated  upon  by  the 
senior  author  at  the  Lankenau  (formerly  German)  Hospital,  the  con- 
cretions were  found  in  the  following  locations: 

In  the  gall-bladder  alone  in 316  or  57  .5  per  cent. 

In  the  gall-bladder  and  cystic  duct 63  or  11 .4  per  cent. 

In  the  gall-bladder  and  common  duct 60  or  10.9  per  cent. 

In  the  gall-bladder  and  hepatic  duct i  or    0.18  per  cent. 

In  the  gall-bladder,  cystic  duct  and  common  duct.  .  3  or    0.5  percent. 

In  the  gall-bladder,  common  duct  and  hepatic  duct.  4  or    0.7  percent. 

In  the  cystic  duct  alone 41  or    7.4  per  cent. 

In  the  cystic  and  common  duct i  or    0.18  per  cent. 

In  the  common  duct  alone 37  or    6.7  percent. 

In  the  gall-bladder,  cystic  duct,  common  duct,  and 

hepatic  duct S  or    0.9  per  cent. 

In  the  common  and  hepatic  ducts 10  or    1.8  per  cent. 

In  adhesions  surrounding  the  gall-bladder 4  or    0.7  per  cent. 

Location  of  stone  not  mentioned  in 4  or    0.7  per  cent. 

Of  far  greater  importance  than  the  mere  presence  of  the  stones 
in  any  case  of  cholelithiasis  is  the  infection  that  may  be  added.  While 
it  is  probably  true  that  a  number  of  those  patients  who  possess  gall- 
stones never  present  symptoms  severe  enough  to  call  their  attention 
to  the  bihary  tract,  it  is  undoubtedly  a  fact  that  these  concretions 
render  persons  so  affected  more  liable  to  infection  of  the  biUary  tract 
than  are  those  who  are  free  from  gall-stones.  Of  476  patients  with 
disease  of  the  biliary  tract,  operated  upon  by  the  senior  author,  389  or 
81.7  per  cent,  had  gall-stones.  When  infection  is  added  to  existing 
biUary  calculi,  the  resulting  pathological  lesions  will  depend  upon 
the  virulence  of  the  invading  micro-organism  and  the  modifying 
resistance  of  the  patient.  They  will  vary  from  a  mild  condition  of 
catarrhal  inflammation  to  a  most  rapid,  wide-spreading  gangrenous 
process.     Lesions  in  all  parts  of  the  biliary  tract  and  adjacent  struc- 


464  SURGERY    OF    THE    GALL-BLADDER    AXD    BILE-DUCTS 

tures  may  be  produced  which  will  result  in  impairment  of  health  if  not 
in  the  death  of  the  patient.  As  Kehr  says:  '"  Gall-stone  disease  enters 
upon  a  period  of  latency  and  can  in  this  quiescence  repose  until  death 
puts  the  man  to  sleep  in  the  eternal  rest  of  the  grave." 

Any  of  those  lesions  discussed  in  the  previous  section  (Chole- 
cystitis and  Cholangeitis)  may  arise  in  cases  of  cholelithiasis;  but 
the  pathological  processes  in  cholelithiasis  are  more  or  less  modi- 
fied by  the  previous  inflammation  of  the  bile-passages,  and  by  the 
mechanical  action  of  the  calculi.  The  gross  pathological  lesions 
found  in  a  series  of  538  cases  of  cholelithiasis  operated  upon  by  the 
senior  author  at  the  Lankenau  (formerly  German)  Hospital  were  as 
follows : 

Lesions  in  538  Cases  of  Cholelithi.\sis 

Cases  Per  cent. 

Cholecystitis,  mild  or  absent' 328  60.9 

Cholecystitis,  acute,  with  catarrh,  ulceration  or  gangrene- 166  30.8 

Hydrops  of  the  gall-bladder 26  4.8 

Carcinoma  of  the  gall-bladder 7  1.3 

Pericholecystitis  with  abscess 7  1.3 

Contracted  gall-bladder,  embedded  in  the  liver i  0.18 

Cholecysto-gastric  fistula 2  0.36 

.•\denomatous  degeneration  involving  liver i  o.  18 

538        99.82 

In  a  further  series  of  804  cases  of  cholelithiasis  operated  on  by  the 
senior  author  (1912-1920),  the  lesions  were  classed  as  follows: 

Lesions  in"  804  Cases  of  Cholelithiasis 

Cases    Per  cent. 

Without  acute  infection ,628  78 .  i 

With:  acute  cholecystitis 37  4.6 

empyema 23  2.8 

hydrops 2  0.2 

gangrene  or  perforation ' 7  0.8 

pericholecystic  abscess i  o.i 

acute  pancreatitis : 8  0.9 

acute  cholangitis 3  0.3 

chronic  pancreatitis 46  5.7 

pancreatic  lymphangitis 40  5.0 

ulcer,  duodenal 7  0.8 

ulcer,  gastric 2  0.2 

804        99  s 

'  In  forty-seven  of  these  cases  there  was  chronic  inflammation  and  contraction  of  the 
gall-bladder. 

'  In  sixty-four  of  these  cases  pus  was  present  in  the  gall-bladder  (empyema). 


PATHOLOGY    OF    CHOLELITHIASIS  4^5 

In  the  vast  majority  of  cases  the  attention  of  the  patient  is  first 
called  to  the  presence  of  gall-stones  by  a  new  invasion  of  the  biliary 
tract  by  bacteria,  or  by  an  acute  exacerbation  of  a  chronic  inflam- 
mation. The  acute  attack  may  be  very  mild  and  fleeting  in  its  course 
and  may  subside  so  rapidly  that  it  may  soon  pass  entirely  from  the 
patient's  memory.  With  each  attack,  however,  changes  occur  in  the 
gall-bladder  causing  that  viscus  to  pass  through  the  various  stages 
of  inflammation  until  it  finally  becomes  contracted,  with  marked 
thickening  of  its  walls.  During  the  progress  of  these  inflammatory 
processes,  the  gall-bladder  may  change  very  decidedly  in  shape  and 
size.  Distinct  pockets  or  diverticula  are  formed  in  some  instances 
or  a  contracting  cicatri.x  will  cause  an  hour-glass  formation;  at  other 
times  the  viscus  will  almost  disappear,  its  remnant  forming  a  tight 
capsule  or  covering  for  one  or  more  calculi.  These  anomalies  have 
been  discussed  at  page  443. 

In  so-called  "simple  cholelithiasis  "  the  symptoms  of  which  are 
in  reality  due  to  a  chronic  catarrhal  cholecystitis,  the  changes  in 
the  walls  of  the  gall-bladder  may  or  may  not  be  very  marked.  There 
may  be  slight  enlargement  of  the  organ  with  some  thickening  of  its 
walls.  The  mucous  membrane  usually  is  somewhat  thickened,  possi- 
bly edematous  and  injected.  As  a  rule  the  bile  is  thicker  than  nor- 
mal, ropy,  and  dark  in  color.  These  conditions  are  not  serious  and 
usually  subside  so  soon  as  the  excitants  of  the  infection,  the  gall- 
stones, have  been  removed.  In  the  absence  of  operative  interference 
the  gall-bladder  and  cystic  duct  only  in  the  rarest  instances  clear 
themselves  of  calculi;  in  such  circumstances  the  bladder  and  duct 
may  resume  their  normal  condition.  Even  when,  after  the  subsi- 
dence of  an  exacerbation,  the  concretions  remain  in  the  gall-bladder 
and  cystic  duct,  or  in  the  gall-bladder  alone,  the  pathological  lesions 
present  may  be  such  that  they  will  not  for  many  years  give  rise  again 
to  symptoms  pointing  to  gall-bladder  trouble. 

The  Cholesterin  Gall-bladder. — Moynihan  has  given  this  name  to 
certain  gall-bladders  whose  walls  seem  normal  on  casual  inspection,  and 
the  mucous  lining  of  which  feels  healthy  to  the  palpating  finger.  The 
contents  are  the  usual  dark  and  tarry  bile  of  the  "stagnant  gall-blad- 
der;" but  on  close  inspection  there  are  found  imbedded  in  the  mucosa 
quantities  of  cholesterin,  as  fine  as  sand;  this  infiltration  of  the  mucosa 
stops  abruptly  at  the  cystic  duct.  Sometimes  minute  crystals  of 
cholesterin  may  be  seen  glistening  on  the  gauze  with  which  the  gall- 
bladder contents  have  come  in  contact;  and  these  will  give  a  clue  to  the 
true  condition  of  the  gall-bladder  walls.     It  will  be  recalled  that  accord- 


466  SURGERY    OF    THE    GALL-BLADDER    AND    BILE-DUCTS 

ing  to  Aschoff  and  Bacmeister  pure  cholesterin  stones  may  be  formed 
without  bacterial  action;  and  !Moynihan  considers  such  gall-bladders  as 
these  typical  examples  of  such  manufactories.  The  cholesterin  sand 
cannot  be  removed.     The  gall-bladder  must  be  e.xtirpated. 

The  Stra-it'berry  Gall-bladder. — Under  this  name  IMacCarty  (1910) 
described  a  form  of  chronic  catarrhal  cholecystitis  in  which  the  gall- 
bladder resembles  at  first  sight  the  cholesterin  gall-bladder  of  Moyni- 
han.  Study,  however,  shows  that  the  yellow  spots  seen  against  the 
reddish  background  are  not  cholesterin  deposits,  but  the  tips  of  villi 
which  have  undergone  desquamation  and  then  become  stained  by  the 
bile.  According  to  studies  made  at  the  Lankenau  Hospital  by  Reimann 
(1919),  "strawberry  gall-bladder"  usually  is  due  to  deposit  of  hpoids 
and  cholesterin  in  the  mucosa  and  submucosa,  these  materials  coming 
from  the  disintegration  of  cells.  \'ery  often  he  found  small  crystalline 
masses  of  cholesterol  or  lipoids  surrounded  by  foreign  body  giant  cells. 
We  attach  no  special  significance  to  such  changes.  These  gall-bladders 
may  or  may  not  contain  stones;  but  in  either  case  their  removal  is 
requisite  to  prevent  recurrence  of  symptoms. 

Pericholecystitis. — When  the  infection  is  of  a  more  virulent  type,  the 
inflammation  will  extend  through  the  walls  of  the  gall-bladder  and 
aflfect  the  visceral  peritoneum,  a  pericholecystitis  resulting.  After 
reaching  the  peritoneum,  the  inflammation  may  extend  to  all  of  the 
adjacent  viscera,  resulting  in  adhesions  matting  together  the  gall- 
bladder, the  omentum,  the  colon,  the  duodenum,  the  liver,  the  stomach, 
and  the  ileum  into  an  unrecognizable  mass.  The  acute  inflammation 
may  again  subside  but  the  changes  wrought  will  be  lasting.  Permanent 
alterations  in  the  gall-bladder  will  be  noted,  and  even  if  the  concretions 
within  the  gall-bladder  remain  more  or  less  quiescent  after  the  sub- 
sidence of  the  inflammation,  symptoms  of  distressing  nature  will  per- 
sist, due  to  the  adhesions  and  the  eft'ect  of  their  contraction  (Fig.  13S). 

Perforation  of  the  gall-bladder  is  a  rare  event  in  cases  of  cholelithia- 
sis, probably  because  the  walls  of  the  gall-bladder  have  become 
resistant  from  the  long-standing  infection,  which  from  the  first  has  been 
of  a  low  grade  of  \irulence.  If,  however,  a  virulent  infection  is  added 
to  a  gall-bladder  already  containing  calculi,  perforation  may  occur 
precisely  as  in  non-calculous  phlegmonous  cholecystitis  (page  453). 
In  the  case  of  calculous  cholecystitis,  however,  the  long  duration  of  a 
mild  infection  or  the  recurrence  of  attacks  of  subacute  inflammation 
usually  has  been  sufficient  to  produce  marked  thickening  of  the  gall- 
bladder walls  (Plate  V),  as  well  as  pericholecystic  adhesions,  so  that 
perforation  into  the  unprotected  peritoneal  cavity  is  extremely  rare. 


Plate  VI 


Gall-bladder  Removed  for  Acute  Calculous  Cholecystitis.  Showing  Xumerous  Stones 
Ulcerating  Through  Walls  of  Gall-bladder.  Count  Showed  a  Total  of  914  Calculi. 
Female,  70  Years.  Recovery.      Path.  No.  8O22.     Lankenau  Hospital. 

Face  p.  466 


PATHOLOGY  OF  CHOLELITHIASIS 


467 


Thus  when  a  perforation  occurs,  the  contents  of  the  gall-bladder,  and 
not  infrequently  the  calculi  themselves,  are  discharged  into  the  sur- 
rounding adhesions,  forming  a  pericholecystic  abscess,  or  even  into 
some  adjoining  hollow  viscus  (stomach,  duodenum,  colon)  if  the  portion 
of  the  gall-bladder  affected  by  perforation  has  been  closely  adherent  to 
such  organ ,  and  the  sloughing  or  ulcerative  process  has  not  been  arrested 


Pig.   138. — Gall-bladder    Distorted  by  Pericholecystic  Adhesions.     {Lankenau  Hospital.) 

spontaneously  before  penetrating  the  walls  of  the  adherent  viscus. 
Sometimes  the  gall-bladder  ulcerates  into  the  liver,  and  an  intrahepatic 
abscess  results.  In  a  few  instances  the  adhesions  will  be  very  slight,  a 
mere  "cob-web,"  and  the  stone  or  stones  will  appear  to  hang  upon  the 
external  surface  of  the  gall-bladder  (Plate  VI) .  If  the  perforation  has 
taken  place  into  a  mass  of  adhesions,  a  swelling  will  be  formed  involving 
any  part  or  all  of  the  upper  right  quadrant  of  the  abdominal  cavity;  the 
inflammation  may  extend  upward  toward  the  diaphragm,  forming  a 


468  SURGERY    OF    THE    GALL-BLADDER    AND    BILE-DUCTS 

subphrenic  abscess;'  it  may  burrow  toward  the  right  kidney  space 
and  simulate  very  closely  a  perinephric  abscess  of  renal  or  spinal  origin. 
Two  such  cases  were  reported  by  Estes  (1905):  the  true  origin  of  the 
condition  was  recognized  only  after  exploratory  incision.  A  rather  un- 
■usual  course  for  the  pus  to  take  in  these  instances  was  reported  by  Jones 
(1907) :  in  this  case  the  pus  burrowed  through  a  mass  of  adhesions  into 
the  right  kidney  space,  forming  a  perinephric  abscess;  and  this  abscess 
opened  into  the  pelvis  of  the  kidney,  biliary  calculi  being  passed  from 
the  urinary  bladder.  Communications  of  the  biliary  passages  with  the 
pleural  cavity  and  bronchi  are  considered  in  connection  with  the  subject 
of  biliary  iistulae  (page  525). 

A  large  majority  of  ulcerative  perforations  of  the  gall-bladder 
occur  in  those  cases  which  have  been  neglected  after  the  onset  of  the 
acute  attack.  When  the  infection  is  very  virulent  it  may  be  possible 
for  the  succeeding  steps  of  inflammation,  ulceration,  and  perforation  to 
occur  so  rapidly  that  operative  treatment  cannot  be  instituted;  but 
usually  the  course  of  the  inflammation  is  slow  enough  to  allow  the  re- 
moval of  the  calculus  or  calculi  with  drainage  of  the  gall-bladder  or 
cholecystectomy.  Early  operative  treatment  of  gall-stone  cases  would 
prevent  in  the  majority  of  instances  the  occurrence  of  perforation  of  the 
gall-bladder  and  its  numerous  sequels. 

Calculi  in  Common  Duct;  Perforation  of  Gall-bladder  into  Lrer;  Sub- 
phrenic   ABSCESS;    ,\bSCESS    IN    GaSTRO-HEPATIC    OMENTUM.      DRAINAGE    OF 

Gall-bladder  and  Common  Duct.     Death  from  Septicemia 

D.  E.,  male,  aged  forty-one  years;  admitted  to  the  German  Hospital  November 
9,  1905.  Has  had  stomach  and  liver  trouble  at  irregular  intervals  for  past  twenty 
years.  Attack  of  heart  trouble  four  years  ago.  Complains  of  dull  pain  below 
ensiform,  which  began  eleven  days  ago.  Pain  referred  to  back  and  to  right  iliac 
fossa.     Vomited  once. 

Examination.- — Liver  extends  from  fourth  rib  10  costal  margin.  Tender- 
ness in  epigastrium  and  over  gall-bladder.  Rigidity  over  gall-bladder.  Respira- 
tions upper  thoracic  and  principally  left  sided. 

Operation,  by  Dr.  Deaver.  Ether  anesthesia.  Incision  splitting  fibres  of  upper 
right  rectus.  Adhesions  throughout  right  hypochondrium.  Gall-bladder  enlarged 
but  collapsed.  Communication  between  gall-bladder  and  abscess  under  diaphragm. 
Abscesses  in  liver,  and  pus  in  gastro-hepatic  omentum.  Three  calculi  in  common 
duct.  Pus  evacuated;  calculi  removed  from  common  duct  b)'  incision;  gall-bladder 
and  common  duct  drained  by  separate  tubes;  gauze  drain  to  subhepatic  space. 
Death  twenty-five  days  after  operation  from  septicemia  and  exhaustion.  No 
autopsy. 

'  This  is  much  more  often  secondary  to  suppurative  hepatitis  (page  540),  though 
Violett,  according  to  Langenbuch  (1897),  recorded  a  case  without  direct  invasion  of  the  liver. 


PATHOLOGY    OF    CHOLELITHIASIS  469 

Perforation  of  the  gall-bladder  into  the  free  peritoneal  cavity  usually 
results  in  a  rapidly  spreading  peritonitis.  Very  seldom  does  it  happen 
that  the  extravasated  bile  is  sterile,  or  so  slightly  infectious  as  to  pro- 
duce no  acute  inflammatory  reaction.  Garre,  in  1904,  found  reports 
of  about  fifty  cases  of  perforation  of  the  gall-bladder  or  ducts  in  cases 
of  cholelithiasis:  in  thirty- three  cases  the  perforation  occurred  in  the 
gall-bladder,  in  one  in  the  hepatic  duct,  in  five  in  the  common  duct, 
and  in  four  in  the  cystic  duct;  while  in  the  remaining  cases  the  site  of 
perforation  was  not  mentioned.  It  is  our  impression  that  the  perfora- 
tion usually  is  at  or  near  the  neck  of  the  gall-bladder  in  calculous  cases, 
while  in  non-calculous  cases  the  perforation  is  more  apt  to  be  near  the 
fundus  of  the  gall-bladder. 

Hydrops  of  the  Gall-bladder ,  already  discussed  at  page  450,  also  occurs 
when  a  calculus  becomes  so  fixed  in  the  cystic  duct  that  the  lumen  of 
the  channel  is  occluded.  The  effect  on  the  gall-bladder  is  the  same  as 
when  this  duct  is  occluded  by  cicatricial  contraction,  but  there  is  much 
greater  likelihood  of  patency  being  restored  in  the  former  than  in  the 
latter  case.  In  some  instances  the  stone  will  cause  sacculation  of  the 
duct,  the  channel  being  very  tortuous.  When  the  obstruction  is 
complete  the  gall-bladder  becomes  distended  with  a  clear  mucoid  fluid, 
the  secretion  of  the  mucous  membrane.  In  cases  of  hydrops  there  is 
seldom  more  than  one  calculus  present — that  causing  the  obstruction. 
This  is  a  radial  cholesterin  stone;  for  other  (secondary)  calculi  to  form 
it  would  be  necessary,  according  to  Aschoff  and  Bacmeister,  for  bile 
to  be  present.  Since  both  in  experimental  ligation  of  the  cystic  duct, 
and  in  malignant  obstruction  of  the  cystic  duct  (lesions  presenting  the 
same  mechanical  conditions  as  impaction  of  a  stone)  the  gall-bladder 
rarely  becomes  distended  (hydrops),  but  usually  shrivels  up,  it  is  clear 
that  in  cases  where  hydrops  does  occur  there  must  be  some  factor 
(in  addition  to  the  mechanical  closure  of  the  duct)  rendering  absorption 
less  than  secretion — perhaps  a  low-grade  hematogenous  infection. 

Calculi  in  the  common  duct  causes  pathological  lesions  that  are  far 
more  serious  than  those  produced  by  stones  in  any  other  situation. 
The  condition  becomes  systemic  rather  than  local,  from  the  direct 
influence  on  the  physiological  activities  of  the  hepatic  ducts  and  their 
radicles,  from  absorption  by  the  lymphatics  along  the  duct  and  from  the 
effect  on  the  gastro-intestinal  tract  by  interference  with  the  functions 
of  the  pancreas  and  the  intestines.  In  exceptional  cases  no  systemic 
effect  is  produced,  the  stone  remaining  in  the  duct  or  passing  through 
it  into  the  duodenum  without  giving  rise  to  other  than  transitory  symp- 
toms, and  no  serious  pathological  lesions  result. 


470  SURGERY   OF   THE   GALL-BLADDER   AND   BILE-DUCTS 

The  relative  frequency  of  stones  in  the  common  duct  is  shown  by  the 
table  at  page  463.  Although  they  were  found  in  the  common  duct 
alone  in  not  quite  7  per  cent,  of  cases,  yet  in  over  21  per  cent,  of  all 
cases  there  were  some  calcuh  in  this  situation.  Robson  found  calculi 
present  in  the  common  duct  in  over  39  per  cent,  of  patients  under  his 
care.  The  more  careful  the  search,  and  the  more  experienced  the 
surgeon,  the  oftener  will  stones  be  found  in  the  deeper  ducts.     A5 

Terrier  used  to  say,  biUary  surgery 
tends  to  become  more  and  more 
"canaliculaire." 

The  position  of  the  stones  in 
the  common  duct  varies  from  its 
beginning  to  its  termination  in  the 
ampulla  of  Vater.  Courvoisier 
found  the  stone,  in  an  anah'sis  of 
123  cases, 

At  the  commencement  of  the  duct 
in  seventeen  cases. 

In  the  middle  part  of  the  duct  in 
nineteen  cases. 

Near  the  retroperitoneal  part  of 
the  duodenum  in  twenty  cases. 

At  the  ampulla  of  \'ater  in  forty- 
one  cases. 

Scattered  along  the  entire  common 
duct  in  twenty-six  cases. 

Langenbuch  said  that  in  two- 

FiG.    139.— Diagram  to  Show  Various  Sites     thirds   of   the  Cases  the  StOUC  is  in 

of  BiUary  Calculi. 

the  duodenal  portion  of  the  com- 
mon duct.  A  calculus  not  infrequently  projects  into  the  duodenum 
through  the  opening  of  the  ampulla  of  Vater.  Calculi  in  this  situation 
usually  are  small;  indeed  Moynihan  clains  that  the  further  down  in 
the  duct  the  calculus  is  found,  the  smaller  it  is  apt  to  be,  the  larger 
stones  almost  invariably  being  found  in  the  upper  portion  of  the  duct. 
As  already  stated,  the  vast  majority  of  bihary  calcuH  originally 
form  in  the  gall-bladder,  and  are  thence  discharged  into  the  cystic, 
and  eventually  into  the  common  bile-duct;  and  when  the  first  stone  has 
become  impacted  in  the  common  duct,  all  others  descending  from  the 
gall-bladder  will  be  dammed  up  behind  it,  until  the  complete  chain 
may  reach  beyond  the  orifice  of  the  cystic  duct  and  fill  the  hepatic  ducts 
also.     It  is  of  course  not  impossible,  when  a  stone  once  has  lodged  in 


PATHOLOGY    OF    CHOLELITHIASIS  47 1 

the  common  duct,  that  other  calculi  not  derived  from  the  gall-bladder 
may  be  formed  subsequently  in  the  ducts  on  the  hepatic  side  of  the 
obstruction.  Such  calculi,  however,  are  almost  invariably  bilirubin 
calcium  stones,  originally  of  very  minute  size  (sand),  which  have 
descended  from  the  intrahepatic  ducts,  and  which  subsequently  increase 
in  size  by  lamination. 

The  number  of  stones  in  the  common  duct  varies  from  one  to  an 
indefinite  number.  The  greatest  number  removed  from  the  common 
duct  by  the  senior  author  is  258.  The  history  of  this  patient  is  of  in- 
terest also  in  showing  the  size  to  which  the  common  duct  may  be  dilated. 

F.  X.,  female,  aged  thirty-four  years.  Admitted  to  the  German  Hospital, 
January  16,  1910.  Family  history  negative.  Past  history  negative.  Has  had 
five  children;  never  has  had  typhoid  fever.  Present  illness:  for  about  nine  years  has 
been  troubled  with  indigestion,  having  epigastric  pain  with  a  sensation  of  stoppage 
of  food  in  this  region;  much  eructation  of  gas.  Since  October,  1907,  has  been  having 
irregular  attacks  of  pain  in  right  hypochondrium,  occurring  about  once  in  two 
months.  The  pain  at  times  is  very  severe,  radiating  to  the  back  and  spine,  and 
requiring  morphine  for  its  relief.  Last  attack  began  January  20,  1910,  and  then 
for  the  first  time  patient  became  jaundiced.  The  pain  is  unaffected  by  posture  or 
eating.  Has  seldom  been  nauseated,  seldom  vomited.  Since  onset  of  jaundice 
stools  have  been  clay-colored.  Patient  was  under  treatment  at  Carlsbad  for  three 
months  last  year. 

Physical  Examination. — Well  developed  and  nourished.  Complexion  markedly 
jaundiced,  of  a  lemon  tint.  Liver  dullness  extends  to  costal  margin.  Mass  felt 
under  costal  margin  in  mid-clavicular  line,  small  in  size  and  tender.  Slight  rigidity. 
No  other  mass.  No  abdominal  distention.  Hemoglobin  82  per  cent.;  R.  B.  C. 
3,410,000;  W.  B.  C,  8,150.  Coagulation-time  ten  minutes.  Urine  contains 
few  granular  and  hyaline  casts.  Bile  test  strongly  positive.  Cammidge  reaction 
positive.  Stool:  weU-formed  masses  of  fatty  consistency,  white,  acid;  occult 
blood  negative;  soaps,  fatty  acid  crystals,  fat,  bacteria,  small  amount  of  vegetable 
material,  few  leukocytes  and  epithelial  cells. 

Operation. — Ether  anesthesia.  Incision  through  upper  right  rectus.  Adhe- 
sions between  gall-bladder  and  omentum.  Adhesions  freed  and  ligated.  Gall- 
bladder incised  and  fifty-five  stones  removed.  Common  duct  found  to  be  distended 
to  size  of  small  intestine  and  filled  with  bUe  and  calculi.  Bile  removed  with 
hypodermic  needle.  Duct  incised  and  258  stones,  varying  in  size  from  a  millet- 
seed  to  a  large  pea,  were  found.  Obstruction  found  in  ampuUa  and  stone  size  of 
hickory  nut  removed  in  pieces,  with  the  scoop.  Gall-bladder,  common  and  hepatic 
ducts  drained. 

Patient  made  a  quick  recovery.  Drainage  fistula  completely  closed  and 
jaundice  was  almost  absent  by  time  of  discharge  from  the  hospital,  twenty-seven 
days  after  operation. 

Complete  occlusion  of  the  common  duct  by  a  stone  is  comparatively 
rare;  partial  obstruction  is  much  more  common.     In  many  instances 


472  SURGERY    OF    THE    GALL-BLADDER    AXD    BILE-DUCTS 

the  gall-stone  remains  in  the  duct  without  causing  any  definite  symp- 
toms of  obstruction,  its  presence  in  the  duct  being  discovered  only  at 
the  time  of  operation  undertaken  for  suspected  stones  in  the  gall- 
bladder. \\  hen  obstruction  takes  place  there  occurs  a  damming  up  of 
bile  with  dilatation  of  the  common  and  hepatic  ducts  and  theii  radicles. 
Dilatation  of  the  duct  will  occur  gradually  to  such  an  extent  that  the 
bile  may  escape  around  the  stone  or  stones,  with  consequent  decrease 
of  the  jaundice.  This  intermittent  type  of  jaundice  was  explained  by 
Fenger  (1896)  by  assuming  that  the  calculus  acted  as  a  ball-valve  in 
the  common  duct,  floating  loose  so  soon  as  a  sufficient  accumulation 
of  bile  had  occurred  behind  it,  and  again  becoming  impacted  as  this 
bile  escaped  on  the  temporary  relief  of  obstruction.  But  this  purely 
mechanical  explanation  is  invalidated  by  later  operative  experience 
which  has  shown  that  in  many  of  such  cases,  if  not  in  all,  the  stone  is 
so  firmly  fixed  in  the  duct  that  by  no  stretch  of  the  imagination  could 
it  have  been  assumed  to  have  been  acting  as  a  ball-valve. 

In  the  patient  whose  history  is  noted  above,  the  common  duct 
equalled  the  small  intestine  in  size;  Langenbuch  refers  to  a  case  recorded 
by 'Schuppell  in  which  the  diameter  of  the  common  duct  was  5  cm.; 
and  Moynihan  mentions  a  specimen  in  the  Museum  of  Guy's  Hospital 
in  which  the  diameter  of  the  common  duct  measured  6  inches.  This 
dilatation  of  the  common  duct  may  be  saccular,  but  usually  is  cylindrical. 

Saccular  cyslic  dilatation  of  the  common  bile-duct  is  comparatively 
rare;  the  condition  sometimes  is  described  as  a  cyst  of  the  common 
bile-duct.  But  as  AlcConnell  (1920),  who  has  collected  36  cases  of  this 
rare  condition,  points  out  it  really  is  not  a  cyst  but  a  diverticulum  of  the 
duct,  which  is  a  congenital  deformity,  having  been  found  in  the  fetus. 
It  is  much  more  frequent  in  the  female  than  the  male,  the  proportion 
being  about  8  to  i.  In  the  twenty-nine  cases  collected  by  Lavenson 
(1909)  the  age  was  stated  in  twenty-two  instances;  the  average  was 
fifteen  years  and  eight  months.  Two  patients  were  under  one  year 
of  age  and  two  were  between  forty  and  fifty  years  of  age. 

The  underlying  cause,  is  some  form  of  obstruction  or  obliteration 
of  the  duct  on  the  distal  side  of  the  enlargement;  for  even  in  cases  which 
are  undoubtedly  due  to  a  congenital  malformation,  progressive  en- 
largement of  the  diverticulum  occurs.  Congenital  obhteration  of  the 
common  duct  (page  441)  might  give  rise  to  such  a  cystic  formation, 
were  life  prolonged  a  sufficient  length  of  time.  In  nineteen  of  the  cases 
collected  by  Lavenson  the  causes  of  the  obstruction  were  as  follows: 
gall-stones  in  three;  papilloma  in  one;  myomyxomatous  pohp  in  one; 
scirrhous  pancreatitis  in  two;  catarrhal  cholangeitis  in  one;  a  simple 


COURVOISIER  S    LAW  473 

stenosis  or  obliteration  of  the  peripheral  end  of  the  lumen  in  six;  a 
valve-like  fold  or  angular  insertion  of  the  duodenal  end  of  the  lumen  in 
five.  Lavenson  states  that  in  addition  to  the  obstruction  of  the  lumen 
of  the  duct,  a  general  weakness  of  the  musculature  of  the  duct  is  present. 
Schlossmann  (191 1)  collected  sixteen  cases  of  what  he  considered 
"idiopathic"  cystic  dilatation  of  the  common  duct. 

The  dilatation  of  the  duct  may  vary  from  that  of  the  index  finger 
to  a  cyst  of  enormous  size.  Weiss  (1909)  reported  a  case  in  which  the 
dilated  duct  contained  800  c.c.  of  slightly  cloudy  biliary  fluid.  It 
simulated  an  echinococcus  cyst. 

The  symploms  of  cystic  dilatation  of  the  common  duct  are  those  of 
obstruction  to  the  normal  flow  of  bile.  According  to  Schlossmann  the 
symptoms  presented  are  merely  intermittent  jaundice  which  may 
continue  for  years;  either  colic-like  or  continuous  abdominal  pain  which 
seems  to  vary  with  the  jaundice;  and  a  tumor  in  the  right  upper  quadrant. 

It  is  practically  impossible  to  make  a  differential  diagnosis  in  all 
cases.  An  enlarged  gall-bladder  or  a  cyst  of  the  pancreas  will  present 
the  same  tumor-like  mass.  We  strongly  advise  against  exploratory 
puncture  in  a  suspected  case,  as  adopted  by  Schlossmann,  on  account 
of  the  great  danger  of  causing  peritonitis.  Exploratory  laparotomy 
is  a  much  safer  procedure. 

The  treatment  should  be  by  operation;  but  the  statistics  collected 
and  analyzed  by  McConnell  (1920)  show  a  very  high  mortality.  Of 
thirty-one  cases  in  which  operative  interference  had  been  instituted, 
there  were  25  deaths;  none  of  the  patients  treated  by  external  drainage 
survived  more  than  a  short  time,  the  immediate  mortality  being 
high;  while  on  the  other  hand  5  patients  in  whom  no  operation  was 
done  survived.  But  among  four  cases  of  cholecystenterostomy  (or 
anastomosis  of  the  diverticulum  with  the  intestine)  there  were  three 
recoveries  (Lavenson).  So  that  it  seems  proper  to  advise  that  if  the 
cyst  cannot  be  extirpated  (a  dangerous  and  difficult  operation),  either 
it  or  the  gall-bladder  should  be  drained  into  the  gastro- intestinal  tract. 
In  McConinell's  patient,  500  cc.  of  bile  were  removed  by  extra- 
peritoneal puncture,  after  exposing  the  very  large  cyst  by  laparotomy; 
three  years  later  the  abdomen  was  reopened  for  recurrence  of  symp- 
toms, and  the  cyst  was  found  much  smaller;  nothing  further  was 
done.  The  patient,  who  suffered  from  cirrhosis  of  the  liver  and  myx- 
edema, was  still  living  at  the  time  of  the  report. 

Courvoisier's  Law. — In  spite  of  enlargement  of  the  ducts  in  com- 
mon duct  obstruction,  the  gall-bladder  itself  seldom  is  enlarged; 
as  a  rule  it  is  contracted.     This  is  in  accord  with  what  is  known  as 


474  SURGERY   OF    THE    GALL-BL.«»DER    AND   BILE-DUCTS 

Courvoisier's  Law^  (i8go)  that  in  80  per  cent,  of  the  cases  of  obstruction 
of  the  common  duct  due  to  stones  there  is  contraction  of  the  gall- 
bladder; while  in  90  per  cent,  of  the  cases  of  enlargement  of  the  gall- 
bladder the  obstruction  is  due  to  causes  other  than  stones. 

Robson    (1904)    gave    the    following   reasons   for    this    condition: 

1.  All  cases  of  cholehthiasis  producing  symptoms  are  accompanied 
by  inflammation  of  the  bihary  passages,  as  shown  by  the  almost 
universal  presence  of  adhesions  around  the  gall-bladder. 

2.  Gall-stones  in  the  common  duct  seldom  cause  complete  ob- 
struction, either  because  they  are  floating  in  the  duct  or  because  they 
only  partly  M  it.  There  is,  therefore,  no  sufficient  backward  pressure 
to  cause  dilatation  of  the  gall-bladder. 

3.  The  muscular  coat  of  the  gall-bladder  contracts  in  efforts  of 
explusion  when  there  is  any  obstruction  in  the  common  duct. 


.^^" 


Pig.  140. — E.xtreme  Contraction  of  Gall-bladder,  the  Result  of  Long-standing  Cholecystitis. 
(Twice  Natural  Size.)     From  a  Patient  in  the  German  Hospital. 

4.  The  co,ntraction,  from  being  at  first  intermittent,  becomes 
in  the  long  run  constant,  and  accompanying  inflammation  fixes  the 
gall-bladder,  which  atrophies  as  a  result. 

The  second  of  the  above  reasons  given  by  Robson  is  consider- 
ably invalidated  by  the  fact  that  the  dilatation  of  the  common  duct 
itself  and  of  the  hepatic  ducts  demonstrates  the  existence  of  back 
pressure;  while  the  fourth  reason  which  is  given  as  a  corollary  of  the 
third,  implies  that  the  gall-bladder  is  in  a  condition  of  spasticity, 
which  is  far  from  being  the  case,  as  its  muscular  walls  are  destroyed 
by  inflammatory  infiltration  long  before  this  stage  of  cholelithiasis 
is  reached.  The  explanation  given  by  Courvoisier  himseK  is  sufficient 
to  account  for  most  cases:  that  the  longstanding  iiiflammatory  con- 
dition of  the  gall-bladder,  whence  in  most  instances  the  stones  originated, 
has  caused  cicatricial  contraction  before  tite  common  duct  becomes  invaded. 

Violations  of  Courvoisier's  Law. — ^Moynihan    (1906)   claims   that 

'  Often  known  also  as  the  Courvoisier-Terrier  Law,  because  the  phenomenon  was 
pointed  out  independently  by  Prof.  Terrier  in  1891  before  Courvoisier's  monograph 
was  known  outside  of  Germany. 


COURVOISIER  S   LAW  475 

Courvoisier 's  law  is  violated  (i)  where  there  is  a  stone  or  stricture  in 
the  cystic  duct  causing  hydrops  or  empyema,  together  with  impaction 
of  stone  in  the  common  duct;  (2)  where  there  is  a  stone  in  the  cystic 
duct  pressing  upon  the  common  duct;  (3)  where  there  is  distention 
of  the  gall-bladder  by  an  acute  inflammatory  process,  with  obstruction 
of  the  common  duct  by  stone;  (4)  where  there  is  chronic  induration 
of  the  head  of  the  pancreas  with  stone  in  the  common  duct;  (5) 
where  there  is  malignant  disease  of  the  common  duct  at  any  part  of 
its  course,  or  cancer  of  the  head  of  the  pancreas,  and  a  chronic  sclero- 
sing cholecystitis. 

The   following   case   history  illustrates   the   conditions   most   fre- 
quently found  in  cases  of  obstruction  of  the  common  duel  by  calculus. 

L.  B.,  female,  aged  thirty-one.  Admitted  to  the  German  Hospital,  January  16, 
1907.  Family  history  negative.  Married  thirteen  years.  Four  pregnancies,  two 
miscarriages.  Bowels  habitually  constipated.  Had  typhoid  fever  eight  years  ago 
at  which  time  she  had  marked  pain  in  the  gall-bladder  region. 

Present  illness  began  in  March,  1906,  with  severe  colicky  pains  in  the  right 
hypochondrium,  radiating  to  the  back  and  right  scapular  region,  and  accom- 
panied by  vomiting.  Confined  to  bed  for  one  week,  then  up  for  a  week  and  again 
confined  to  bed  for  eight  weeks.  Had  constant  pain  in  the  gall-bladder  region, 
with  exacerbations  of  pain.  Was  able  to  be  out  of  bed  until  September,  1906, 
during  which  period  she  did  not  feel  well,  had  marked  constipation,  no  appetite, 
and  would  perspire  freely  on  exertion.  In  September  was  seized  with  excruciating 
pain  in  right  hypochondrium,  similar  to  first  attack,  but  much  more  severe.  Did 
not  vomit.  Had  chill  before  onset  of  pain.  Denies  presence  of  jaundice  in  either 
attack.  Following  this  attack  was  fairly  well  until  two  weeks  before  admission  to 
hospital  when  she  had  attack  of  pain  similar  to  the  former  attacks.  Did  not  know 
she  was  jaundiced  until  told  so.  Great  depression  of  spirits,  appetite  very  poor. 
Bowels  markedly  constipated.  Jaundice  of  skin  and  sclerae.  Considerable 
tenderness  over  gall-bladder  region.  Lower  border  of  liver  palpable  below  costal 
margin.  Abdomen  soft  except  in  the  right  hypochondrium  where  there  is  some 
rigidity.  Hemoglobin,  80  per  cent.,  W.  B.  C,  5900.  Coagulation  time,  two 
minutes. 

Operation,  January  19,  1907.  Ether  anesthesia.  Incision  through  upper 
right  rectus.  Adhesions  between  gall-bladder,  duodenum,  great  omentum  and 
transverse  colon.  Gall-bladder  thickened,  contracted  and  empty.  All  ducts 
thickened  and  surrounded  by  adhesions.  Hepatic  and  common  ducts  greatly 
dilated.  Common  duct  opened  below  junction  of  cystic  and  hepatic  ducts.  Probe 
passed  into  ampulla  of  Vater  where  a  calculus  was  found.  Calculus  worked  upward 
and  removed  through  opening  in  duct.  Rubber  drainage  introduced  into  common 
and  hepatic  ducts.  Cystic  artery  and  cystic  duct  ligated,  gaU-bladder  removed. 
Gauze  drainage  along  bed  of  gaU-bladder  and  into  subhepatic  space.  Wound 
closed  to  drainage  with  iodine  gut.  Jaundice  disappeared  three  days  after  opera- 
tion. Recovery  uneventful.  Culture  of  gall-bladder  showed  pure  growth  of 
Bacillus  typhosus. 


476  SURGERY    OF    THE    GALL-BLADDER   AND   BILE-DUCTS 

Enlargement  of  the  liver  generally  follows  obstruction  of  the  com- 
mon duct,  the  smaller  biliary  radicles  becoming  much  dilated;  in  the 
course  of  time  they  may  even  produce  a  sort  of  varicose  appearance 
on  the  surface  of  the  liver.  The  back  pressure  eventually  causes 
atrophy  of  the  hepatic  cells,  and  along  with  inflammatory  changes 
due  to  infected  bile,  is  responsible  for  the  formation  of  new  connective 
tissue  in  the  substance  of  the  liver,  surrounding  each  biliary  radicle. 
This  is  followed  by  atrophy  of  the  parenchyma  of  the  liver,  so  that 
there  eventually  is  found  a  relatively  increased  proportion  of  con- 
nective tissue  to  the  secreting  parenchyma,  and  the  liver  becomes 
decreased  in  size.  This  condition  closely  resembles  chronic  cirrhosis, 
but  Kelly  (1908)  distinguished  between  the  present  condition,  which 
he  termed  chronic  hepatitis,  and  true  cirrhosis. 

Calculi  in  the  common  duct  frequently  are  productive  of  marked 
changes  in  the  pancreas.  These  are  considered  in  Chapter  XXL  Ex- 
tension of  the  common  duct  infection  may  occur  by  contiguity  also  to  the 
portal  vein,  and  rare  cases  are  on  record  of  portal  and  even  splenic  throm- 
bosis, and  of  suppurative  hepatitis  due  to  embolism  from  these  sources. 

Calculi  in  the  hepatic  duct  are  rare.  In  the  senior  author's  series 
of  549  cases  of  cholelithiasis  (page  463),  there  was  only  one  in  which  the 
stones  were  found  in  the  hepatic  duct  alone;  in  twenty  cases  (3.6  per 
cent.)  calculi  in  the  hepatic  ducts  existed  coincidently  with  stones  in 
other  locations,  but  with  the  one  exception  noted  above  in  every  case  of 
hepatic  duct  stone  there  were  also  calculi  in  the  common  duct.  In  one 
other  case  not  included  in  this  series  the  senior  author  removed  a  single 
iarge  stone  from  the  hepatic  duct.  Courvoisier  found  that  among 
fifty-nine  cases  of  stones  in  the  hepatic  duct  there  were  also  stones  in 
other  locations  in  no  less  than  fifty-six  cases.  These  figures  make  it  evi- 
dent that  in  the  'Vast  majority  of  cases  calculi  in  the  hepatic  duct 
have  not  originated  in  that  situation  but  have  either  migrated  first 
from  the  gall-bladder  and  cystic  duct  into  the  choledochus,  and  have 
thence  floated  up  into  the  hepaticus;  or,  what  is  certainly  much  rarer, 
have  formed  in  the  choledochus  or  in  the  common  hepatic  duct  as  a 
result  of  calculous  or  other  inflammatory  obstruction  of  the  lower 
portion  of  the  choledochus. 

The  pathological  changes  induced  by  stones  in  the  hepatic  duct  are 
not  to  be  distinguished  froin  those  due  to  common  duct  lithiasis. 

Predisposing  Causes. — Age. — It  is  impossible  to  determine  defi- 
nitely at  what  age  biliar\-  calculi  arc  formed,  because  no  one  can  decide 
how  long  they  may,  or  may  not,  remain  quiescent  after  their  formation. 
Between  50  and  60  per  cent,  of  the  cases  that  come  to  operation  are  over 


PREDISPOSING    CAUSES    OF    CHOLELITHIASIS  477 

forty  years  of  age  and  less  than  i  per  cent,  are  under  twenty.  It  is  our 
belief,  based  upon  clinical  experience,  that  most  gall-stones  are  formed 
between  the  ages  of  twenty  and  forty,  when  the  system  is  most  liable  to 
the  other  infectious  diseases  such  as  typhoid  fever,  appendicitis,  etc. 

It  is  not  at  all  unusual  to  note  in  the  history  that  the  "present 
illness"  began  five  or  ten  years  before  admission  to  the  hospital.  If  the 
time  of  the  onset  of  the  present  illness  were  taken  as  the  time  of  the 
formation  of  the  gall-stones,  it  would  be  clearly  demonstrated  that 
cholehthiasis  is  a  disease  of  early  adult  Hfe  and  not  of  advanced  age; 
and  if  it  be  remembered  that  even  these  first  symptoms  may  not 
appear  until  years  after  the  formation  of  the  stone,  this  supposition  is 
strengthened. 

The  above-mentioned  opinion  is  at  variance  with  the  teachings 
of  many  of  the  older  writers.  Hoppe-Seyler  states  that  "the  increasing 
frequency  of  gall-stones  with  advancing  years  is  very  striking.  Friedr. 
Hoffmann,  Morgagni,  Haller,  Coe,  J.  P.  Frank,  and  others  have  em- 
phasized this  fact,  and  it  is  established  by  all  autopsy  reports.  As  the 
latter  alone  furnish  conclusive  evidence,  we  are  justified  in  believing 
that  such  a  connection  exists." 

It  is  probable  that  these  investigators  were  greatly  influenced 
by  the  incidence  of  gall-stones  at  various  ages.  Necropsy  reports 
are  the  only  ones  that  are  reliable  in  determining  the  prevalence  of 
gall-stones  at  different  periods  of  life;  but,  on  the  other  hand,  they  are 
just  as  unreliable  in  determining  the  part  age  plays  as  an  etiological 
factor  in  the  formation  of  gall-stones,  for  the  reason  that  biUary  calculi 
may  remain  latent  for  years  after  their  formation  without  giving  rise  to 
symptoms  that  will  call  attention  to  their  presence.  Hoppe-Seyler 
states  that  "in  many,  in  fact  the  majority  of  the  cases  of  concretions 
within  the  gall-bladder  or  the  bile-passages,  all  symptoms  are  absent, 
and  the  condition  is  only  discovered  at  autopsy.  Whenever  the  stones 
remain  in  the  location  where  they  are  formed,  i.e.,  in  the  gall-bladder, 
they  usually  produce  no  symptoms." 

As  has  already  been  pointed  out.  catarrhal  inflammation  of  the 
gall-bladder  is  believed  to  be  one  of  the  necessary  factors  in  gall- 
stone formation;  and  the  typhoid  bacillus  and  the  colon  bacillus 
which  are  the  organisms  found  most  frequently  in  cholelithiasis, 
are  most  active  in  the  human  subject  during  the  period  between  twenty 
and  forty  years  of  age,  when  typhoid  fever,  appendicitis,  catarrhal 
inflammation  of  the  intestines,  etc.,  are  most  frequent.  These  two 
bacteria  were  found  in  37.2  per  cent,  of  the  bacteriological  examinations 
made  by  Kelly  in  patients  with  cholelithiasis  operated  upon  by  the 


478  SURGERY    OF    THE    GALL-BLADDER    AXD   BILE-DCCTS 

senior  author  at  the  German  Hospital,  while  55.4  per  cent,  of  the  cultures 
remained  sterile  (page  415). 

There  is  no  age  at  which  gall-stones  may  not  be  found,  John 
Thomson  even  claiming,  according  to  Still  (1899),  that  most  of  the 
gall-stones  of  early  infancy  are  prenatal  in  origin,  an  infection  of  the  bi- 
hary  tract  taking  place  during  intrauterine  life  which  in  one  instance 
will  cause  obKteration  of  the  bile-ducts,  in  another  the  formation  of 
stones.  Still  collected  twenty-three  cases  of  cholehthiasis  in  children 
under  fourteen  j'ears,  including  three  cases  of  his  own;  fourteen  of  the 
collected  cases  were  under  ten  months  of  age ;  several  were  in  still-born 
infants;  his  own  three  patients  were  each  less  than  nine  months  old. 

Sex. — Sex  has  a  most  decided  influence  on  gall-stone  formation. 
The  chnical  experience  of  the  senior  author  places  the  preponderance 
of  women  over  men  nearly  as  four  to  one:  of  606  cases  of  cholelithiasis 
461  or  76.1  per  cent,  were  females  and  145,  or  23.9  per  cent,  were 
males. 

The  greater  frequency  of  gall-stone  disease  in  women  is  due  to 
conditions  which  favor  stasis  of  bile  in  this  sex.  Chief  among  these 
is  the  habit  of  wearing  tight  corsets.  Rother,  according  to  Moyni- 
han,  found  corset-Uver  in  40  per  cent,  of  women  suffering  from  gall- 
stones; and  Schroeder  (1892)  found  gall-stones  in  59  per  cent,  of  cases 
of  corset-Hver.  But  even  when  tight  lacing  is  not  carried  to  the  degree 
necessarj'  to  produce  a  corset-liver  Umitation  of  the  excursions  of  the  dia- 
phragm, caused  by  any  constriction  of  the  waist,  interferes  with 
the  natural  discharge  of  bile  from  the  gall-bladder  (page  37). 

Pregnancy  also  is  important  as  a  predisposing  factor  in  chole- 
lithiasis; it  has  been  shown  (Payr)  that  during  pregnancy  the  cholesterol 
content  of  the  blood  is  increased.  And  the  influence  of  pregnancy 
does  not  cease  with  the  emptying  of  the  uterus.  WTiile  this  organ  is 
enlarged  during  the  child-bearing  period  pressure  is  exerted  on  all  the 
abdominal  viscera,  and  the  free  evacuation  of  the  gall-bladder  is  hin- 
dered by  this  pressure.  After  pregnane)^  terminates  there  often  is  a 
ptosis  of  the  abdominal  organs  with  twisting  or  kinking  of  the  cystic 
duct,  caused  by  traction,  or  at  times,  by  torsion.  Cholelithiasis  seems 
to  occur  much  more  frecjuently  in  those  women  who  have  been  pregnant, 
and  especially  in  those  who  have  borne  many  children,  than  in  those 
whose  uterus  has  never  been  gra^^d.  Mayo  (191 1)  says  ''90  per  cent, 
of  married  women  who  have  gall-stones  have  borne  children,  and 
90  per  cent,  of  these  women  identify  the  beginning  of  symptoms  with 
some  particular  pregnancy." 

The   more   frequent   occurrence,    in    the   female   sex,    of   movable 


PREDISPOSING   CAUSES    OF    CHOLELITHIASIS  479 

kidney,  especially  of  the  right  kidney,  is  also  regarded  as  a  predisposing 
cause  of  gall-stone  formation,  since  by  traction  on  the  duodenum  the 
bile-ducts  may  be  displaced  or  kinked  (page  521). 

Climate. — From  statistics  that  have  been  gathered  from  numerous 
sources  by  various  investigators,  it  has  been  demonstrated  that  chole- 
lithiasis is  much  more  frequently  seen  in  some  localities  than  others. 
The  cause  of  the  greater  frequency  in  these  localities  is  not  the  climate 
or  the  altitude,  however,  but  rather  the  different  modes  of  living  and 
the  greater  prevalence  of  infectious  diseases  which  cause  catarrhal 
conditions  of  the  gastro-intestinal  and  biliary  tracts. 

Race. — This  also,  seems  to  be  a  predisposing  cause  of  choleli- 
thiasis. Our  clinical  experience  places  the  Hebrew  race  in  the  fore- 
ground in  relation  to  the  frequency  with  which  gall-stones  are  found 
among  the  different  races.  Probably  this  is  to  bp  attributed  to  their 
sedentary  habits.  The  African  race,  on  the  other  hand,  seems  to  be 
almost  immune  from  gall-bladder  affections. 

Occupation. — Sedentary  habits  must  be  placed  in  this  category. 
Statistics  quoted  by  Douglas  (1903)  show  that  cholehthiasis  is  exceed- 
ingly common  among  teachers,  clergymen  and  the  insane.  But  this 
frequency  is  attributable  not  to  the  cerebral  activity,  but  to  the  con- 
finement and  sedentary  habits  involved,  which  favor  stasis  of  bile. 

Cardiac  lesions  which  cause  stagnation  of  the  bile  may  create  a 
catarrhal  condition  of  the  mucous  membrane,  by  venous  stasis,  or  by 
rendering  the  patients  sedentary  in  their  habits,  etc.  Rolleston  (1905) 
showed  by  the  report  of  the  Manchester  Royal  Infirmary,  analyzed  by 
Brockbank,  that  gall-stones  are  found  twice  as  often  in  those  patients 
who  have  cardiac  lesions  prior  to  their  fatal  illness  as  in  those  without 
such  heart  conditions. 

The  presence  of  any  joreign  body  in  the  biliary  tract  may  act  as  a 
predisposing  cause  of  gall-stone  formation,  as  it  may  become  the 
nucleus  of  the  subsequently  formed  calculus.  Intestinal  parasites, 
fruit  kernels,  silk  threads,  and  other  foreign  bodies  have  been  noted  as 
forming  nuclei  of  biliary  concretions.  Experiments  performed  by 
Mignot  prove  that  foreign  bodies  may  remain  in  the  gall-bladder  indefi- 
nitely if  they  are  free  from  germ-life  without  causing  inflammation 
or  precipitation  of  the  soHds  of  the  bile.  There  must  be  added  an 
attenuated  bacterial  infection  to  cause  the  formation  of  calculi. 

Any  septic  condition,  especially  in  the  abdominal  cavity,  predisposes 
to  infections  of  the  bihary  tract,  by  acting  as  a  focus  from  which  bac- 
teria may  be  carried  to  the  bile-passages,  through  the  systemic  or  the 
portal  circulation.     If  the  infection  is  attenuated  when  it  reaches  the 


480  SURGERY    OF    THE    CALL-BLADDER    AND    BILE-DUCTS 

gall-bladder,  gall-stone  formation  may  result,  if  the  other  essentials 
are  present. 

Peritoneal  adhesions,  from  any  cause,  will  act  as  a  predisposing 
cause  of  gall-stone  formation  by  favoring  stasis  of  the  bile,  through 
distortion  or  kinking  of  the  bile  ducts.  In  the  same  way,  gastroptosis, 
coloptosis,  cecum  mobile,  displacement  of  the  right  kidney,  constipa- 
tion, marked  obesity,  or  any  factor  causing  stasis  of  bile,  may  be 
regarded  as  a  predisposing  cause  of  cholelithiasis. 

Degeneration  of  the  thyroid  gland  and  the  ovaries  is  a  predisposing 
factor  in  gall-stone  formation,  according  to  the  views  of  Lorand  (1906), 
who  claims  that  as  these  glands  govern  oxidation  aud  obesity,  degenera- 
tive changes  in  them  will  cause  atony  of  the  biliary  ducts,  pathological 
alterations  in  the  liver,  atony  of  the  intestine,  constipation,  etc.,  with 
resulting  stagnation  of  bile. 

Exciting  Causes. — The  exciting  etiological  factor  in  cholelithiasis 
used  to  be  assigned  to  heredity,  to  cirrhosis  of  the  liver,  to  gout,  to 
rheumatism,  to  faulty  metabolism,  to  errors  and  indiscretions  in 
diet,  to  excessive  use  of  alcohol,  to  digestive  disturbances,  etc.  Modern 
science  has  removed  all  of  these  from  the  domain  of  exciting  factors 
of  cholelithiasis  and  has  placed  them  either  in  the  category  of  predis- 
posing causes,  or  entirely  without  the  realm  of  etiological  factors, 
whether  exciting  or  predisposing.  There  is  but  one  exciting  cause  of  • 
gall-stone  formation  and  that  is  an  invasion  of  the  biliary  tract  by 
attenuated  bacterial  infection  in  the  presence  of  a  stasis  of  bile. 

A  bacterial  study  of  gall-stones  shows  the  presence  of  bacteria  in 
about  ^^  per  cent.  Such  studies,  however,  are  of  no  value  in  determin- 
ing the  action  of  bacteria  as  the  underlying  factor  in  gall-stone  forma- 
tion. It  has  been  stated  by  numerous  investigators  and  has  been 
proved  experimentally  both  in  animals  and  in  the  test-tube,  that  gall- 
stones may  rid  themselves  of  bacteria  after  their  formation;  and,  on  the 
other  hand,  that  biliary  calculi  may  absorb  bacteria  from  the  surround- 
ing bile.  Thus  it  is  quite  possible  to  obtain  colon  bacilli  from  a  gall- 
stone whose  formation  was  due  to  typhoid  infection,  or  vice  versa;  to 
obtain  sterile  cultures  from  biliary  concretions  universally  acknowledged 
to  owe  their  origin  to  bacteria,  and  to  obtain  cultures  of  bacteria  which 
had  nothing  to  do  with  the  formation  of  the  particular  stone  from  which 
they  were  grown.  No  reliance  should  be  placed  on  the  results  of  bac- 
terial investigation  in  the  case  of  stones  that  have  been  examined 
months,  perhaps  years,  after  their  formation.  If,  however,  bacterio- 
logical examinations  were  to  be  made  soon  after  the  formation  of  the 
calculi,  while  they  were  still  soft,  and  before  the  gall-bladder  had  had 


.      SYMPTOMS    OF    CHOLELITHIASIS  48 1 

an  opportunity  to  rid  itself  of  bacteria,  micro-organisms  would  be 
found  in  every  calculus  with  very  few,  if  any,  exceptions.  According 
to  Funke  (1906)  soft  concretions  invariably  yield  bacteria. 

S}rmptomatology  and  Diagnosis. — The  symptoms  of  cholelithiasis 
are  presented  in  almost  endless  combination.  A  study  of  the  patho- 
logical changes  due  to  the  presence  of  biliary  calculi  with  added  infec- 
tion shows  how  this  is  possible,  and  will  enable  the  surgeon  so  to  inter- 
pret the  signs  and  symptoms  presented  that,  as  a  rule,  not  only  a  correct 
diagnosis  of  the  presence  of  stones  may  be  made,  but  also  of  their 
exact  location  and  of  the  pathological  lesions  which  will  be  disclosed 
by  direct  inspection  of  the  affected  part.  It  is  essential,  therefore,  for 
anyone  who  attempts  to  diagnose  and  treat  diseases  of  the  liver  and  the" 
biliary  tracts  to  be  thoroughly  conversant  with  their  pathology.  With- 
out such  knowledge  it  will  be  impossible  to  interpret  correctly  the  signs 
and  symptoms  presented  and  as  a  consequence  the  patient  will  sufifer 
from  faulty  treatment.  In  the  majority  of  cases  of  cholelithiasis  the 
diagnosis  is  easy:  symptoms  and  signs  are  presented  which  enable  one 
to  arrive  readily  at  definite  conclusions.  In  the  minority  of  cases, 
however,  it  may  be  impossible  to  make  a  correct  pathological  diagnosis; 
and  in  some  cases  a  diagnosis  can  be  made  only  after  the  abdomen  has 
been  opened  and  the  affected  region  has  been  examined  by  sight  and 
touch. 

If  the  conclusions  of  Kehr.  with  which  Riedel  agrees,  are  to  be 
accepted,  95  per  cent,  of  the  patients  possessing  gall-stones  do  not 
present  symptoms  which  direct  attention  to  their  presence.  We  cannot 
agree  with  these  findings,  although  the  opinions  of  such  eminent  clini- 
cians must  be  given  due  weight.  We  fully  agree  that  the  majority  of 
cases  do  not  present  the  symptoms  commonly  recognized  as  classical 
in  this  condition;  on  the  other  hand,  we  believe  that  symptoms  are 
present  which  usually  are  misunderstood.  Such  symptoms  may  be 
elicited  by  studying  carefully  the  history  of  the  case.  Notes  of  former 
illness,  of  "bihousness,"  of  attacks  of  "indigestion,"  etc.,  should  be 
made  fully  and  in  minute  details.  Inquiry  regarding  attacks  of  pain, 
no  matter  how  remote,  should  be  made,  and  the  rephes  noted.  The 
presence  or  absence  of  nausea  or  vomiting,  of  flatulence,  or  constipa- 
tion, of  fever,  of  chills,  or  of  jaundice  during  any  period  in  the  past 
history  should  be  carefully  noted.  Negative  findings  often  are  as 
valuable  as  are  positive,  in  arriving  at  a  correct  diagnosis. 

Many  symptoms  of  choleUthiasis  which  often  are  classified  vaguely 
as  stomach  and  liver  troubles,  "biliousness,"  "indigestion,"  "dyspep- 
sia," etc.,  will  be  found  in  such  a  history,  and  will  often  lead  to  the 

31, 


482  SURGERY   OF    THE    GALL-BLADDER    AND   BILE-DUCTS 

diagnosis  of  biliary  calculi  before  any  marked  symptoms  have  presented 
themselves.  Riedel  (1903)  claimed  that  "cramps"  in  the  stomach  are 
caused  by  gall-stones  in  ninety-seven  out  of  100  cases.  When  the  so- 
called  classical  sjnaiptoms  are  present  there  is  little,  if  any  difficulty  in 
making  the  diagnosis. 

Gall-stones,  unaided  by  infection,  present  scarcely  any  sjonptoms. 
All  signs  and  sj-mptoms  presented  during  the  course  of  gall-stone 
disease,  are  due,  we  beheve,  to  inflammation  of  the  bihary  tract  resulting 
from  infection.  The  symptoms  vary  with  the  severity  and  chronicity 
of  the  infection. 

Pain  is  the  most  constant  symptom  of  cholelithiasis  and  one  of  the 
most  important  to  be  studied  in  making  a  diagnosis.  It  is  caused  in  all 
cases,  we  believe,  by  infection  or  the  results  of  infection  of  the  biliary 
tract  and  never  is  due  to  the  mere  presence  of  the  gall-stones.  In  a 
series  of  549  cases  operated  upon  by  the  senior  author  at  the  German 
Hospital,  pain  was  present  in  539  or  98.2  per  cent.,  and  was  absent  or 
not  obtainable  in  the  history  of  only  ten,  or  1.8  per  cent. 

It  is  convenient  to  discuss  the  s^-mptoms  of  pain  in  cases  of  chole- 
lithiasis under  the  headings  of  local  and  referred  pain,  a  plan  followed  by 
Moynihan. 

Local  pain,  which  will  be  considered  first,  is  met  with  in  two  main 
tj-pes,  the  first  embracing  what  are  now  generally  recognized  as  the 
"gastric  s}-mptoms"  of  cholelithiasis,  and  the  second  being  the  classical 
"biliary  colic."  The  "gastric  symptoms"  of  cholelithiasis  frequently 
are  followed  by  symptoms  of  acute  calculous  cholecystitis  without  the 
patient  ever  experiencing  an  attack  of  biliary  colic.  (The  symptoms  of 
acute  cholecystitis  have  been  considered  at  page  454.) 

Gastric  Symptoms. — The  earUest  symptom  generally  is  pain  of 
a  character  and  location  that  is  very  misleading  to  the  patient  and  to 
many  medical  observers.  The  patient  attributes  this  initial  pain  to  a 
bihous  attack,  to  gastralgia,  to  dyspepsia,  to  neuritis,  to  gastritis,  to 
indigestion,  in  fact,  to  anything  except  to  gall-stones.  It  is  described 
by  the  patient  as  dull,  burning,  gnawing,  boring,  grasping,  etc.  As  a 
rule  it  is  confined  to  the  epigastrium.  These  "gastric  symptoms"  have 
been  described  as  prodromal  symptoms  which  "are  said  to  indicate  the 
impending  formation  of  gall-stones"  (Hoppe-Seyler) .  Later  study  has 
shown  them  to  be  symptoms  caused  by  gall-stones  confined  to  a  gall- 
bladder in  which  there  is  very  mild  acute  or  chronic  catarrhal  inflamma- 
tion, the  latter  affecting  the  gall-bladder  alone,  while  the  cystic  duct  is 
occluded  momentarily  if  at  all.  and  the  to-and-fro  motion  of  the  bile  is 
practically  normal.     It  is  recognized  as  gall-stone  pain  by  the  irregu- 


BILIARY   COLIC  483 

larity  of  its  occurrence  and  by  its  dejiendence  on  no  recognized  factor. 
It  may  occur  at  night  or  during  the  day  and  be  independent  of  the 
ingestion  of  food  or  of  the  kind  of  food.  As  Graham  says  "these  are 
light  attacks  of  distress,  gas,  upward  pressure,  coming  often  soon  after 
food  or  at  irregular  times,  often  of  sudden  onset,  short  duration,  eased 
by  belching  or  perhaps  slight  vomiting,  regurgitation,  or  slipping  away 
almost  unnoticed  and  without  treatment."  No  particular  effect  is 
produced  on  the  patient's  constitution,  and  good  nutrition  is  main- 
tained.    This  initial  pain  is  never  of  a  colicky  character. 

It  was  pointed  out  at  page  142  that  pylorospasm,  gastro-succor- 
rhea,  etc.,  are  not  infrequently  due  to  cholelithiasis;  and  we  have 
repeatedly  called  attention  to  the  fact  that  gastric  lesions  are  often 
secondary  to  infections  of  the  bihary  tract. 

There  may  be  slight  tenderness  on  pressure  over  the  gall-bladder 
(see  page  487),  but  more  moderate  pressure  in  this  region  will  reheve 
whatever  pain  is  present.  Some  writers  have  noted  a  heavy  dragging 
pain  or  sensation  due  to  the  weight  of  the  secretions  within  the  gall- 
bladder. Our  clinical  experience  has  failed  to  confirm  such  findings  in 
any  case.  When  this  symptom  occurs,  some  pathological  lesion  either 
than  biliary  concretions  within  the  gall-bladder  will  be  present  to 
account  for  it.  Pericholecystic  adhesions,  carcinoma  or  other  complic- 
ations will  be  found,  and  it  is  in  such  cases  that  referred  pain  occurs 
(page  485). 

With  more  active  inflammation  of  the  gall-bladder,  the  symp- 
toms presented  are,  first,  those  of  cholecystitis  (page  454);  later  there 
occur  the  symptoms  of  the  complications  that  arise  during  the  inflam- 
mation, or  those  of  the  sequels  that  follow  its  subsidence.  As  has 
already  been  pointed  out  a  persistent  chronic  cholec3'stitis  usually 
remains  after  gall-stone  formation;  and  this  chronic  condition  is  liable 
to  be  interrupted  by  attacks  of  inflammation  more  or  less  acute  in  type. 

Biliary  Colic. — The  typical  "biliary  colic"  of  the  text-books  is 
present  in  a  great  majority  of  cases  that  are  operated  upon,  but  it  is  not 
to  be  found  in  all  of  them.  In  the  previously  mentioned  series  of  549 
cases  of  cholelithiasis,  pain  of  a  distinctly  colicky  character  was  noted 
in  462  or  82.3  per  cent.;  and  was  unrecognized  by  the  patient  at  any 
time  in  ninety-seven  or  17.6  per  cent.  This  colicky  pain  is  caused  by 
muscular  contraction  of  the  gall-bladder  or  ducts,  and  is  not  due  directly 
to  the  movements  of  a  stone  either  in  the  gall-bladder  or  through  the 
ducts,  although  movements  of  the  stones  may  add  to  the  severity  of  the 
cohc.  It  is  well  known  that  in  exceptional  cases  biliary  calculi  are 
recovered  from  the  feces  of  patients  who  have  never   suffered  from 


484  SURGERY   OF   THE    GALL-BLADDER    AND   BILE-DUCTS 

"biliary  colic;"  and  that  attacks  of  biliary  colic  are  very  seldom  fol- 
lowed by  the  passage  of  a  calculus;  while  every  surgeon  of  experience 
has  operated  on  patients  who  have  never  passed  any  stones  in  spite 
of  numerous  attacks  of  cohc,  and  yet  in  whom  no  gall-stones  were  to  be 
found  at  the  time  of  the  operation. 

Biliary  colic,  in  other  words,  is  the  equivalent  of  renal  colic,  appendicu- 
lar colic,  and  intestinal  colic:  in  all  varieties  the  pain  is  not  primarily 
caused  by  the  passage  of  a  foreign  body,  but  by  disordered  and  violent 
peristaltic  action  of  the  diseased  organ,  which  has  been  excited  in  the 
effort  to  overcome  an  obstacle  to  its  evacuation.  This  obstacle  is 
rarely  a  foreign  body  in  the  nature  of  a  calculus;  almost  invariably  it  is 
due  to  some  other  form  of  obstruction,  either  stenosis  of  the  lumen 
from  acute  inflammatory  edema,  to  kinks  produced  by  displacement 
of  the  organ  aft'ected,  or  to  viscosity  of  its  secretion.  There  is  disten- 
tion of  the  gall-bladder  or  ducts  with  bile  and  mucus,  and  an  attempt 
to  force  a  passageway  through  the  duct.  If  an  obstruction  in  the 
cystic  duct  is  relieved  by  a  stone  returning  to  the  body  of  the  bladder 
or  by  the  subsidence  of  the  inflammatory  obstruction  at  the  mouth  of 
the  duct,  the  pain  disappears  at  once,  the  gall-bladder  emptying  itself 
through  the  duct.  In  the  mildest  cases  the  pain  may  be  fleeting;  of 
such  short  duration,  in  fact,  that  the  patient  will  soon  forget  that  he 
has  experienced  it  and  can  recall  it  only  after  the  most  thorough 
questioning.  This  acute,  initial  attack  of  mild  colic  causes  no  pain, 
as  a  rule,  in  the  region  of  the  gall-bladder — the  pain  is  in  the  mid-epigas- 
tric region.  In  other  cases,  however,  the  initial  attack  is  severe,  sudden, 
overwhelming.  A  man,  believing  himself  to  be  in  the  enjo^Tnent  of 
perfect  health,  except  for  shght  gastric  symptoms  which  have  never 
seriously  annoyed  him,  may  suddenly  have  a  dreadful  cramp  in  his 
upper  abdomen;  he  bends  forward,  pressing  his  hands  or  the  back  of  a 
chair  into  his  belly;  breaks  out  in  a  cold  sweat;  becomes  deathly  pale 
and  feels  faint;  is  nauseated;  and  sometimes  his  distress  is  relieved  by 
vomiting.  At  other  times  he  will  writhe  around  his  bed,  or  even  on 
the  floor,  in  utmost  agony.  Hot  applications  to  the  epigastrium  or 
h}T)ochondrium  maj'  have  scarcely  any  effect  on  the  pain,  and  even 
morphin  hypodermically  does  not  always  bring  relief  as  soon  as  could 
be  wished.  Death  sometimes  occurs  during  the  paroxysm  (Lange- 
buch,  1897).  The  fever  which  follows  the  sweat  may  rise  to  104°  F., 
or  higher. 

When  the  obstruction  is  not  relieved  the  pain  will  be  more  lasting, 
remaining  for  hours  or  even  days,  not  so  intense  as  at  first,  but  still 
severe.     The  pain  now  passes  to  the  gall-bladder  region,  with  pain 


REFERRED   PAIN   IN    CHOLELITHIASIS  48$ 

referred  to  the  back  and  shoulder.  This  pain  is  significant  because 
it  usually  indicates  that  there  are  taking  place,  in  the  neck  of  the  gall- 
bladder or  in  the  cystic  duct,  changes  which  will  result  in  permanent 
damage  to  these  structures.  The  obstruction  may  be  relieved  by  a 
stone  passing  through  the  cystic  duct,  or  by  the  subsidence  of  the  acute 
inflammation  of  the  duct,  but  the  lesions  will  be  permanent  and  the 
parts  cannot  again  return  to  a  normal  condition.  Simple  hydrops, 
empyema,  gangrene,  or  perforation  may  result. 

With  complete  obstruction  of  the  cystic  duct  resulting  in  simple 
hydrops,  colicky  pain  usually  disappears;  with  incomplete  obstruction 
the  colic  continues  indefinitely.  In  the  latter  class  of  cases,  there  often 
is  a  referred  pain  in  the  right  iliac  fossa,  at  times  paroxysmal  and  sharp, 
resembling  in  many  respects  the  pain  found  in  connection  with  an 
impacted  ureteral  calculus. 

When  the  inflammation  involves  the  common  duct,  or  when  a 
stone  in  its  passage  has  reached  this  location,  the  colicky  pain  will  be 
felt  in  the  right  hypochondrium,  usually  associated  with  referred  pain 
in  the  right  shoulder.  Subsidence  of  the  inflammation  will  be  followed 
by  cessation  of  pain,  even  if  a  gall-stone  remains  in  the  duct. 

Yet  even  during  the  intervals  between  attacks  or  in  the  cases  of 
patients  who  have  had  no  distinct  attacks  of  bihary  coHc,  there  is 
seldom  a  feeling  of  perfect  comfort  in  the  gall-bladder  region.  The 
symptoms  of  indigestion,  of  gastric  flatulence,  etc.,  after  meals,  will 
persist,  perhaps  becoming  more  pronounced ;  the  clothes  will  be  loosened 
around  the  waist;  and  moderate  pressure  or  support  with  the  hand 
to  the  right  hypochondrium  will  be  attempted  to  relieve  the  dragging 
sensation  usually  significant  of  pericholecystic  adhesions,  and  chronic 
choleUthiasis.  Langenbuch,  and  later  Moynihan,  have  called  particu- 
lar attention  to  a  sensation  of  chilliness,  during  the  evening,  as 
particularly  suggestive  of  mild  infection  of  the  gall-bladder. 

Referred  Pain.^As  pointed  out  at  page  26  the  various  positions  to 
which  pain  caused  by  affections  of  the  liver  and  biliary  track  may  be 
referred  can  readily  be  explained  by  a  knowledge  of  the  nerve  supply 
of  the  organs  involved.  The  liver  and  biliary  tract  are  supplied  by 
three  nervous  systems,  the  cranial,  the  spinal,  and  the  sympathetic. 
These  connections  have  been  well  summarized  by  Millard  (1907). 

The  tenth  cranial,  or  pneumogastric  nerve,  distributes  sensory 
fibres  to  the  esophagus,  the  stomach,  the  lungs,  and  special  fibres  to 
the  heart,  liver,  spleen,  pancreas,  kidneys,  suprarenal  bodies  and  the 
intestinal  blood-vessels.  The  spinal  system  is  represented  by  the 
phrenic  nerve  which  is  derived  mainly  from  the  fourth  cervical  nerve,  a 


486  SURGERY    OF    THE    GALL-BLADDER   AND   BILE-DUCTS 

branch  of  which,  the  supraacromial,  is  distributed  to  the  integument 
of  the  point  of  the  shoulder.  The  phrenic  distributes  fibres  to  the 
diaphragm  and  falciform  ligament  of  the  liver;  it  unites  with  filaments 
of  the  celiac  plexus  to  form  the  diaphragmatic  plexus  which  is  joined 
by  filaments  fiom  the  diaphragmatic  ganghon.  From  this  plexus 
fibres  are  distributed  to  the  coronary  Hgaments  and  peritoneum  of  the 
liver  and  to  the  right  suprarenal.  The  sympathetic  nerve  supply  is 
derived  from  the  celiac  plexus,  which  is  joined  by  branches  from  both 
semilunar  ganglia  and  from  the  right  pneumogastric.  From  it  arise 
the  coronary,  hepatic,  and  splenic  plexuses.  The  hepatic  plexus  in- 
osculates with  fibres  from  the  left  pneumogastric  and  enters  the  liver. 
Filaments  are  distributed  to  the  right  suprarenal;  other  filaments 
follow  the  branches  of  the  hepatic  artery. 

On  account  of  this  general  intercommunication  of  the  nerve  supply 
of  the  liver,  biliary  apparatus  and  other  regions  of  the  body,  pain  caused 
by  lesions  of  these  organs  may  be  referred  to  various  positions.  It  may 
be  purely  epigastric;  may  occur  in  the  right  or  left  hypochondrium; 
in  either  kidney  region;  in  the  diaphragmatic  area,  in  the  cardiac  region, 
or  in  the  left  lung;  in  the  back;  beneath  either  shoulder  blade;  at  the  tip 
of  the  shoulder;  or  throughout  the  abdomen. 

In  the  earliest  stages  of  cholelithiasis,  where  the  gastric  sjinptoms 
predominate,  the  pain  rarely  is  referred.  Sometimes  a  dull  aching, 
a  feehng  of  discomfort,  is  experienced  to  the  right  of  the  spinal  column. 
When  the  disease  has  lasted  for  some  time,  and  pericholecystic  adhe- 
sions have  developed,  imphcating  the  pylorus,  the  pain  may  be  referred 
to  the  left  subscapular  region  (p.  4). 

In  attacks  of  biliary  colic  the  pain  is  ver}-  constantly  referred, 
either  to  the  right  shoulder,  to  the  right  chest,  or  more  rarely  to  the 
right  groin.  In  colic  from  involvement  of  the  common  bile-duct 
the  entire  lower  right  thorax  may  be  painful,  from  swelling  of  the 
liver. 

The  character,  location,  and  duration  of  pain  are  important 
diagnostic  factors  both  in  the  diagnosis  of  infections  of  the  biliary 
tract  and  in  the  differential  diagnosis  of  all  other  lesions  in  the  upper 
portion  of  the  abdomen.  The  pecuharities  of  the  pain  should  be 
carefully  considered  whenever  present;  and  if  absent  this  fact  should 
alwa3-s  be  noted. 

Pain  in  "gastric  symptom  cases"'  of  cholelithiasis  is  dull,  burning, 
gnawing,  boring,  or  grasping.  It  is  confined  to  the  epigastrium  or 
possibly  referred  to  the  back.  It  is  independent  of  the  ingestion  of 
food  or  of  the  kind  of  food.      It  nia\"  occur  at  night  or  during  the  day. 


TENDERNESS    IN    CHOLELITHIASIS  487 

The  pain  of  more  severe  infection  of  the  biliary  tract  is  cohcky 
in  character,  very  severe,  of  sudden  onset,  usually  of  short  dura- 
tion, and  of  sudden  cessation.  It  is  felt  in  the  epigastrium  or  the 
right  hypochondrium  and  may  be  referred  to  the  breast,  back,  right 
costal  arch,  right  shoulder,  shoulder  blades,  etc.  The  attacks  are 
independent  of  the  ingestion  of  food  and  usually  of  the  kind  of  food. 
They,  may  occur  at  night  or  on  an  empty  stomach.  The  intervals 
between  attacks  may  vary  from  hours  or  days  to  years. 

The  pain  in  tilcer  of  the  stomach  usually  is  of  a  stabbing  character, 
located  in  the  epigastrium,  being  referred  at  times  to  the  left  hypochon- 
drium or  left  scapular  region.  It  is  rarely  present  when  the  stomach 
is  empty,  but  follows  the  ingestion  of  food  either  immediately  or 
within  half  an  hour,  and  often  increases  in  severity  until  the  stomach 
has  been  emptied  by  vomiting  or  by  the  expulsion  of  stomach  con- 
tents into  the  duodenum.  The  pain  is  seldom  absent  for  any  long 
periods  of  time. 

The  pain  in  ulcer  of  the  duodenum  usually  recurs  during  definite 
periods  of  time,  the  duration  of  the  periods  varying  from  a  few  days 
to  several  months.  During  these  periods,  the  pains  will  appear 
daily  or  several  times  a  day.  They  are  burning  and  gnawing  in 
character,  and  radiate  to  the  region  of  the  stomach  and  duodenum. 
They  bear  a  regular  relation  to  the  patient's  meals:  they  are  at  their 
height  from  two  to  six  hours  after  the  ingestion  of  food,  and  are  relieved 
or  entirely  dissipated  by  food  or  drink  or  by  removal  of  the  contents 
of  the  stomach  either  by  vomiting  or  by  irrigation.  Between  these 
periods  the  patient  considers  himself  in  perfect  health;  whereas  in 
choleKthiasis  a  certain  amount  of  gastric  distress  is  constantly  present 
even  during  the  intervals  of  freedom  from  acute  symptoms. 

The  pain  in  cancer  of  the  stomach  is  more  or  less  continuous,  of  a 
dull,  depressing  character.  It  is  generally  increased  by  the  ingestion 
of  food. 

Tenderness  obtained  by  pressure  or  palpation  is  closely  allied 
to  pain  in  all  cases  of  cholelithiasis.  Some  writers  lay  much  greater 
stress  on  certain  points  of  tenderness  or  pain  elicited  by  pressure, 
than  on  any  other  symptom.  This  tenderness  is  claimed  by  some 
to  indicate,  absolutely,  by  its  presence  or  absence,  the  presence  or 
absence  of  gall-stones.  Robson  and  Cammidge  (1909)  state  that 
"another  characteristic  symptom  of  great  diagnostic  value  is  the 
existence  of  a  tender  spot  an  inch  above  the  umbilicus,  and  in  a  Hne 
between  it  and  the  right  costal  margin.  This  tender  spot  is  quite 
as  constant  as  the  McBurney  point  in  appendicits.  although  in  some 


488 


SURGERY   OF    THE    GALL-BLADDER    AND   BILE-DUCTS 


cases  it  may  be  a  little  higher  than  that  mentioned,  but  in  the  same 
line."     This  is  frequently  spoken  of  as  "Robson's  point." 

This  characteristic  point  of  tenderness  may  also  be  elicited  in  the 
following  manner,  usually  called  the  Murphy  method.  With  the 
patient  sitting  up  and  leaning  forward,  the  examiner  stands  back  of 
the  patient  with  one  hand  hooked  under  each  costal  margin  at  the 
ninth  costal  cartilage.  Deep  inspiration  forces  the  liver  and  gall- 
bladder downward  while  the  finger-tips  press  inward  and  upward. 
In  this  way  pressure  on  the  kidney  is  avoided,  while  tenderness  from 
the  stomach  or  duodeum  is  much  more  superficial.     Pain  is  experienced 


Fig. 


141. 


-Palpation  of  the   Gall-bladder  by   "Thumb  Pressure' 
Cartilage. 


under  the  Ninth  Costal 


by  the  patient  as  pressure  is  exerted  on  the  deep-lying  gall-bladder 
and  the  inspiration  is  checked  suddenly  by  the  pain,  the  patient  being 
unable  to  take  a  full  inspiration.  While  we  believe  that  this  tender- 
ness is  very  significant  of  the  presence  of  biliary  calculi,  it  is  scarcely 
warrantable  to  go  as  far  as  Bishop  (1907),  who  said  that  "if  the  result 
of  such  examination  is  negative,  the  possibility  of  biliary  calcuU  is 
eliminated."  ]\Ionsariat  (1908)  claimed  that  this  tenderness  is  the 
one  persistent  clinical  sign  upon  which  a  diagnosis  may  be  made. 
This  tender  point  is  also  elicited  by  "thumb  pressure"  under  the 
ninth    costal    cartilage,    after    the   manner   practised   by    Moynihan. 


TENDERNESS    IN    CHOLELITHIASIS 


489 


The  left  hand  is  placed  over  the  lower  right  thorax  as  the  surgeon 
sits  or  kneels  at  the  right  side  of  the  patient's  bed,  and  the  thumb 
of  this  hand  presses  firmly  but  gently  over  the  region  of  the  gall- 
bladder just  below  the  costal  border.  Or  the  surgeon  may  employ 
the  method  which,  according  to  Langenbuch,  was  originally  recom- 
mended by  Rheinstein  (1891):  The  left  hand  is  placed  under  the 
patient  so  as  to  steady  the  lower  right  thorax;  then  by  bimanual 
palpation,  using  the  right  hand  over  the  upper  abdomen,  the  two 
hands  are  gently  but  firmly  approximated,  and  as  the  right  kidney 


Fig.  142. — Bimanual  Palpation  of  the  Gall-bladder. 


and  the  liver  are  pushed  forward,  the  tenderness  due  to  the  diseased 
gall-bladder  becomes  evident  at  the  end  of  deep  inspiration  (Figs.  141, 
142). 

No  undue  force  should  be  used  in  palpating  the  gall-bladder  region, 
for  rupture  of  a  diseased  gall-bladder  has  been  recorded  (Langen- 
buch) as  due  to  such  manoeuvres. 

There  also  is  very  constantly  a  tender  spot  in  Boas's  area,  on  the  right 
side  behind,  at  the  level  of  the  twelfth  dorsal  vertebra,  two  or  three 
finger  breadths  from  the  spine,  and  this  may  be  present  even  when  no 
tenderness  can  be  discovered  in  front. 

While  these  tender  spots  are  of  significance  when  present,  their 
absence  does  not  preclude  the  presence  of  gall-stones.     Our  clinical 


490  SURGERY    OF    THE    GALL-BLADDER    AND    BILE-DUCTS 

experience  has  been  unable  to  confirm  the  constancy  of  these  diagnos- 
tic signs  as  observed  by  others.  They  have  been  absent  or  not  obtain- 
able in  a  number  of  cases,  especially  in  some  "gastric  symptom  cases" 
where  the  gall-stones  and  the  inflammation  have  been  confined  to 
the  inside  of  the  gall-bladder.  Where  there  is  or  has  been  perichole- 
cystic  inflammation,  tenderness  is  much  more  constant.  In  such 
cases  slight  rigidity  of  the  over-lying  muscles  is  present,  while  in  cases 
of  cholelcystitis.  and  other  acute  phases  of  gall-bladder  disease,  both 
tenderness  and  rigidity  are  pronounced. 

Enlargement  of  the  Gall-bladder. — The  gall-bladder  is  enlarged 
in  the  majority  of  cases  of  cholelithiasis,  but  the  enlargement  may  not 
be  sufficient  to  cause  the  presence  of  a  palpable  tumor,  on  account 
of  the  position  of  the  gall-bladder  in  its  fossa  on  the  under  surface  of  the 
right  lobe  of  the  Uver.  The  normal  gall-bladder  cannot  be  felt  through 
the  abdominal  wall;  when  the  gall-bladder  is  palpable  it  must  be  dis- 
tended sufficiently  to  force  its  fundus  beyond  the  border  of  the  liver. 
It  is  possible  for  the  gall-bladder  to  be  very  tense  without  there  being 
a  palpable  tumor,  since  the  gall-bladder  wall  may  be  thickened  and 
sclerotic  from  long-standing  disease,  and  be  incapable  of  further  dis- 
tention; thus  is  it  not  unusual  to  find  a  small  contracted  gall-bladder 
full  of  pus  (empyema),  and  very  tense.  In  a  series  of  in  cases  of 
cholelithiasis  operated  upon  by  the  senior  author,  the  gall-bladder  was 
distended  in  seventy-four,  or  66.6  per  cent.;  it  was  normal  in  size 
in  seven,  or  6.3  per  cent.;  and  was  contracted  in  thirty,  or  27  per 
cent. 

The  position  of  the  gall-bladder  varies  with  the  size  and  position 
of  the  liver;  in  normal  conditions,  the  neck  of  the  gall-bladder  is 
about  on  a  level  with  the  ninth  costal  cartilage.  In  cases  of  ptosis 
of  the  liver  or  enlargement  of  that  organ,  the  neck  of  the  gall-bladder 
may  be  as  low  as  the  umbilicus  or  even  below  that  point.  If  the  gall- 
bladder is  enlarged  the  fundus  usually  moves  downward  and  forward, 
although  it  is  not  rare  to  find  the  tumor  extending  toward  the  median 
line,  nor  is  it  unusual  to  find  at  operation  that  the  gall-bladder,  though 
enlarged,  is  hidden  behind  the  liver  and  therefore  was  not  palpable 
through  the  abdominal  walls.  In  some  instances  it  has  extended  to  the 
brim  of  the  pelvis,  and  in  this  position  has  been  mistaken  for  an  ovarian 
tumor  (page  451). 

When  the  distention  of  the  gall-bladder  is  sufficient  to  form  a 
palpable  tumor,  the  latter  will  be  felt  as  a  rounded,  smooth  pear- 
shaped  mass,  readily  movable  laterally  in  the  absence  of  adhesions. 
In  the  presence  of  pericholecystic  adhesions,  the  tumor  may  not  be 


FEVER    IN    CHOLELITHIASIS  49I 

recognizable  as  the  gall-bladder,  the  characteristic  shape  and  smooth- 
ness being  absent.  Under  these  conditions  a  mass  will  be  palpable, 
more  or  less  fixed.  The  mass  may  move  with  res])iration  or  be  fixed 
to  the  anterior  abdominal  wall.  When  the  gall-bladder  is  free  there  is  a 
distinct  movement  with  respiration,  the  dome  of  the  tumor  passing 
under  the  palpating  hand  with  each  respiratory  movement. 

In  the  more  severe  infections  it  is  often  impossible  to  determine  the 
presence  of  a  tumor,  even  though  it  may  be  very  evident  at  operation, 
on  account  of  the  rigidity  of  the  overlying  muscles.  There  must 
be  more  or  less  laxity  of  the  abdominal  muscles  in  the  right  upper 
quadrant,  if  the  gall-bladder  is  to  be  palpated. 

The  enlarged  gall-bladder,  unless  held  in  place  by  adhesions, 
may  be  moved  or  pushed  from  its  normal  location,  but  will  return 
immediately  when  relieved. 

A  tumor  of  the  gall-bladder  without  jaundice  usually  indicates 
closure  of  the  cystic  duct,  generally  by  a  calculus. 

A  tumor  of  the  gall-bladder  with  jaundice,  is  indicative  of  pressure 
from  without,  in  about  90  per  cent,  of  such  cases.  Jaundice  due  to 
calculus  obstruction  usually  is  accompanied  by  a  contracted  gall- 
bladder (see  page  473) .  Enlargement  of  the  gall-bladder  with  jaundice 
usually  is  significant  of  carcinoma  of  the  head  of  the  pancreas,  of 
the  duodenum,  or  of  the  common  duct;  or  of  benign  disease  of  the 
pancreas. 

Fever. — An  increase  of  temperature  at  time  of  operation  for  chole- 
lithiasis is  noted  in  about  one-third  of  the  cases.  In  a  series  of  368 
cases  of  cholelithiasis  operated  upon  by  the  senior  author,  fever  was 
absent  in  264,  or  68.4  per  cent.;  and  was  present  in  122  or  31.6  per 
cent.  The  rise  in  temperature  is  due  to  an  infectiousprocess,  and  natur- 
■  ally  is  absent  except  during  the  activity  of  the  infection.  With  the 
subsidence  of  the  acute  infection,  the  fever  disappears.  So  long  as 
the  infection  is  confined  to  the  gall-bladder  there  rarely  is  any  marked 
rise  in  temperature,  since  the  gall-bladder  is  nearly  devoid  of  lymph 
nodes  and  very  little  absorption  occurs  from  it.  But  when  the  infec- 
tion spreads  either  to  the  surrounding  peritoneum  or  to  the  bile-ducts, 
then  marked  temperature  changes  occur.  The  temperature  in  cases  of 
cholangeitis,  biliary  hepatitis,  etc.,  may  resemble  that  of  malaria  or 
or  septicemia.  In  such  cases  the  sudden  onset  of  fever,  its  rapid 
rise  to  a  height  if  101°  F.,  or  more,  and  its  quick  fall  again  to  the  normal, 
are  quite  characteristic,  the  temperature  forming  what  Moynihan  has 
well  named  a  "steeple"  chart.  There  is  entire  absence  of  fever  between 
the  excerbations. 


492  SURGERY    OF    THE    GALL-BLADDER    AND   BILE-DUCTS 

Vomiting. — \'omiting  usually  is  present  during  the  attacks  of 
biliary  colic,  and  usually  is  absent  between  the  attacks.  At  times  it 
begins  with  the  termination  of  the  attack  of  colic;  first  the  ingested  food 
and  later  bilious  matter  being  rejected.  Blood  is  very  rarely  present. 
The  vomiting  often  seems  to  relieve  the  pain.  In  rare  instances  the 
vomiting  may  be  persistent,  even  alarming. 

Vomiting  in  iiker  of  the  stomach  is  almost  as  constant  as  is  pain  in 
that  affection.  Vomiting  usually  brings  absolute  rehef.  The  vomitus 
is  sour,  often  contains  an  excessive  amount  of  liquids,  and  is  streaked 
with  blood  in  over  25  per  cent,  of  the  cases. 

Vomiting  in  itlcer  of  the  duodenum  usually  increases  in  severity 
with  the  progress  of  the  disease,  at  times  becoming  alarming.  It 
usually  occurs  about  two  to  four  hours  after  the  ingestion  of  food,  at 
the  time  the  pain  and  gas  are  greatest.  The  vomitus  is  "acid,"  "acrid," 
"bitter-burning,"  rather  small  in  amount  but  very  irritating.  It 
sometimes  contains  blood. 

Vomiting  in  cancer  of  the  stomach  is  irregular.  Some  relief  is  gen- 
erally afforded.  The  vomitus  is  foul-smelling  and  consists  of  partly 
digested  food  and  contains  altered  blood  in  about  two-thirds  of  the 
cases. 

Crepitation. — In  a  few  instances  a  strong  crepitation  may  be  elicited 
by  pressure  on  a  gall-bladder  containing  calcuh.  LeBlanc  (1906) 
reported  such  a  case,  in  which  auscultation  also  elicited  a  sound  exactly 
similar  to  the  crepitus  of  a  fractured  bone.     Such  cases  are  rare. 

Tetany  has  been  referred  to  at  page  158  as  frequently  of  gastro- 
intestinal origin.  It  is  occasionally  observed  on  the  subsidence  of  a 
severe  attack  of  biliary  colic. 

Roentgenography,  for  a  long  time  considered  a  very  unrehable 
aid  in  the  detection  of  bihary  calculi,  has  been  so  developed  in  recent 
years  that  it  must  be  regarded  almost  as  indispensable  as  in  the  diag- 
nosis of  kidney  stones.  But  it  must  be  remembered  that  even  in  the 
absence  of  stones,  the  biliary  tract  may  be  very  seriously  diseased,  and 
a  negative  X-ray  e.xamination  should  not  be  held  to  contraindicate 
exploratory-  operation,  when  the  history  and  clinical  symptoms  indicate 
this  to  be  proper. 

Localization  of  Gall-stones.^ — In  most  cases  of  cholelithiasis  it  is 
possible  to  ascertain  with  a  fair  degree  of  accuracy  whether  the  calculi 
still  remain  in  the  gall-bladder  or  whether  they  have  escaped  into  the 
bile-ducts,  and  if  so  whether  the  common  duct  is  involved.  As  calculi 
may  be  found  in  several  ducts  as  well  as  in  the  gall-bladder  at  the  same 
time,  the  clinical  picture  may  be  somewhat  confusing;  but  a  distinction 


SYMPTOMS   OF    STONE   IN   THE    CYSTIC   DUCT  493 

between  stones  still  in  the  gall-bladder,  those  in  the  cystic  duct,  and 
those  in  the  common  duct,  usually  can  be  made  by  attention  to  the 
history  of  the  case  and  a  careful  physical  examination. 

The  symptoms  and  signs  of  stones  in  the  gall-bladder  alone  ("  simple 
cholelithiasis"  as  it  is  called)  are  those  of  chronic  catarrhal  cholecystitis. 
There  may  be  an  occasional  exacerbation  resulting  in  acute  cholecystitis, 
or  in  gall-stone  colic;  and  it  is  chiefly  on  the  recurrence  of  symptoms  that 
the  diagnosis  of  gall-stones  is  based.  A  single  attack  of  cholecystitis, 
even  with  severe  colic,  is  not  enough  to  warrant  a  diagnosis  of 
stone. 

Stone  in  the  Cystic  Duct. — The  frequency  of  this  localization  of  gall- 
stones is  shown  in  tabular  form  at  page  463.  Including  cases  where 
calculi  are  found  elsewhere  in  the  bile-tract  as  well  as  in  the  cystic  duct, 
this  portion  of  the  tract  is  involved  in  about  20  per  cent,  of  cases.  The 
symptoms  and  signs  vary  with  the  size  of  the  stone,  the  acuteness  of 
the  inflammation,  and  the  completeness  of  the  obstruction.  As  soon 
as  a  stone  impinges  upon  the  mouth  of  the  duct  or  enters  its  lumen, 
typical  gall-stone  colic  results  from  the  attempt  to  rid  the  duct  of  the 
obstruction.  Paroxysms  of  pain  recur  until  the  stone  either  passes 
through  the  duct,  returns  to  the  gall-bladder,  or  becomes  lodged  perma- 
nently in  the  duct.  In  the  latter  case  obstruction  is  not  necessarily 
complete,  since  usually  a  portion  of  the  lumen  remains  through  which 
bile  can  pass.  Should  the  obstruction  become  complete,  however,  the 
pain  will  disappear  as  further  atempts  at  dislodgment  gradually  cease. 
The  pain  of  obstruction  of  the  neck  of  the  gall-bladder  is  referred  to 
the  right  shoulder-blade  in  70  per  cent.,  to  the  left  scapular  re- 
gion in  10  per  cent.,  and  to  the  sternum,  precordial  region,  and  right 
subclavicular  region  in  20  per  cent,  of  cases,  according  to  McBurney 
(1907). 

Jaundice  is  not  present  in  uncomplicated  cases  of  calculus  in  the 
cystic  duct.  The  presence  of  jaundice  implies  cholangeitis  and  obstruc- 
tion of  the  common  or  hepatic  duct. 

The  presence  or  absence  of  enlargement  of  the  gall-bladder  depends 
upon  the  character  and  degree  of  inflammation  in  the  organ  before  the 
stone  enters  the  duct,  and  upon  the  completeness  of  the  obstruction. 
When  there  has  been  previous  inflammation,  the  gall-bladder  walls 
usually  are  thickened  and  contracted;  or  the  entire  organ  may  beheld 
fast  by  surrounding  adhesions.  In  these  cases  no  enlargement  of  the 
gall-bladder  will  occur.  In  the  majority  of  instances,  however,  a 
dilatable  gall-bladder  is  present,  enlargement  occurs  and  the  gall- 
bladder can  be  palpated.     If  obstruction  of  the  duct  is  complete,  no 


494  SURGERY    OF    THE    GALL-BLADDER    AND   BILE-DtXTS 

bile  can  enter,  and  the  gall-bladder  becomes  distended  with  its  secretion, 
forming  hydrops  vesica  fellcce,  the  symptoms  of  which  were  considered 
at  p.  455.  Should  acute  infection  occur  in  the  gall-bladder  em- 
pyema develops.  The  sj-niptoms  of  this  condition  were  discussed  at 
page  456. 

The  diagnosis  of  obstruction  of  the  cystic  duct  depends  upon  a 
correct  interpretation  of  the  symptoms  enumerated  above,  and  on  the 
recognition  of  enlargement  of  the  gall-bladder.  When  the  gall-bladder 
is  small  or  contracted  or  bound  down  by  adhesions  it  is  nearly  impos- 
sible to  make  a  diagnosis  of  obstruction  of  the  cystic  duct.  ^Moreover, 
enlargement  of  the  gall-bladder  may  be  caused  by  any  condition  which 
causes  obstruction  to  the  flow  of  bile,  or  even  b}'  the  presence  of  a  large 
number  of  calculi  within  the  gall-bladder. 

Pressure  on  other  structures  exerted  bj-  a  stone  in  the  cystic  duct 
may  give  rise  to  symptoms  that  will  make  the  diagnosis  more  difEcult. 
Thus  cholangeitis  and,  at  times,  obstructive  jaundice  may  result  from 
pressure  on  the  common  duct;  thrombosis  and  ascites  may  result  from 
pressure  on  the  portal  vein;  sjiiiptoms  of  gastric  dilatation  may  result 
from  pressure  on  the  duodenum.  But  these  conditions  are  compara- 
tively rare,  and  the  history  of  the  case  should  aid  in  clearing  up 
the  diagnosis,  especially  when  enlargement  of  the  gall-bladder  is 
present. 

The  prognosis  in  obstruction  of  the  cystic  duct  is  good,  unless 
the  contents  /of  the  gall-bladder  become  infected  so  virulently 
that  acute  empyema,  perforation  or  gangrene  results.  The  prog- 
nosis under  such  conditions  is  very  grave.  In  uncomplicated  cases 
the  operative  mortality  is  no  higher  than  that  of  cholecystectomy  in 
general. 

Stone  in  the  Common  Duct. — The  frequencj-  of  stone  in  the  com- 
mon duct  was  discussed  at  page  463.  Including  cases  where  calculi 
are  found  elsewhere  as  well  as  in  the  common  duct,  this  is  involved  in 
over  21  per  cent,  of  the  cases.  The  more  experienced  a  surgeon  becomes, 
the  less  apt  is  he  to  let  a  stone  in  the  common  duct  remain  undetected 
at  operation. 

The  symptoms  presented  are  pain  of  a  colicky  nature,  followed 
in  most  instances  b)^  jaundice  which  is  intermittent  and  which  varies 
greatly  in  intensity  even  when  present.  The  attacks  of  pain  often 
are  associated  with  intermittent  feverish  attacks,  and  with  chills;  and 
in  most  instances  such  attacks  are  followed  by  an  increase  in  intensity 
of  the  jaundice.  The  chain  of  symptoms  presented  is  similar  to  that 
of  "Charcot's  Intermittent  Fever,"  a  type  of  cholangeitis  associated 


SYMPTOMS    OF    STONE   IN    THE    COMMON    DUCT  495 

with  obstruction  of  the  common  duct.  The  symptoms  of  cholangeitis 
have  been  described  at  page  448. 

There  is  no  enlargement  of  the  gall-bladder  in  uncomplicated 
cases  of  obstruction  of  the  common  duct  by  calculus.  There  are 
few  exceptions  to  this  rule;  they  have  been  discussed  at  page  474. 

The  diagnosis  of  calculous  obstruction  of  the  common  duct  depends 
largely  upon  the  history  of  the  case.  If  the  patient  is  seen  during  an 
attack  of  acute  cholangeitis  it  may  be  possible  to  make  a  diagnosis  even 
in  the  absence  of  an  accurate  history.  Obstruction  of  the  common  duct 
by  calculus  may  be  differentiated  from  that  due  to  carcinoma  of  the 
duct  by  the  train  of  symtoms  usually  noted  in  the  latter  affection. 
Chronic  progressive  jaundice,  without  fever,  with  decoloration  of  the 
stools,  absence  of  sharp  pain,  moderate  enlargement  of  the  liver,  a  dis- 
tended gall-bladder,  and  <  ontinuous  emaciation,  are  characteristics  of 
obstruction  from  cancer  of  the  common  duct  (page  588).  Obstruction 
of  the  common  duct  from  enlargement  of  the  head  of  the  pancreas,  as  a 
result  either  of  inflammation  or  of  a  new  growth,  is  considered  at  page 

695- 

The  prognosis  of  calculous  obstruction  of   the  common  duct  is 

very  much  graver  that  where  the  cystic  duct  alone  is  obstructed. 

The  danger  is  in  large  part  due  to  the  more  serious  lesions  present, 

but  in  no  small  degree  to  the  more  extensive  operative  interference 

required  to  assure  removal  of  all  calculi.     The  mortality  of  chole- 

dochotomy  varies  from  7  to  30  per  cent.,  in  various  statistics. 

Treatment  of  Cholelithiasis 

After  the  discussion  of  the  pathology  of  this  affection,  into  which 
we  have  gone  at  some  length,  it  scarcely  seems  necessary  to  insist 
further  on  the  fact  that  cholelithiasis  is  a  surgical  disease,  and  that 
operative  treatment  is  requisite  for  its  cure.  Kocher's  oft-quoted 
epigram  that  gall-stones  belong  primarily  not  to  the  surgeon  but  to  the 
patient,  is  true  enough;  but  the  modest  statement  of  fact  which  he 
appends  should  not  be  overlooked.  It  is  to  the  effect  that  it  is  the  pa- 
tient's privilege,  if  he  so  elects,  to  spend  an  invalid's  life  sojourning 
from  time  to  time  at  the  various  resorts  such  as  Carlsbad,  Marienbad, 
Saratoga,  etc.,  thus  cautiously  endeavoring  to  keep  his  calculi  quietly 
at  rest  in  his  gall-bladder;  or  even  to  endure  with  fortitude  the  occa- 
sional agony  induced  when  a  calculus  leaves  the  gall-bladder  and  at- 
tempts to  force  its  passage  into  the  bowel.  But  this  life  is  only  for  the 
well-to-do  classes;  as  Kehr  says,  at  Carlsbad  the  poor  disappear  abso- 


496  SURGERY    OF    THE    GALL-BLADDER    AXD    BILE-DUCTS 

lutely;  "the  patients  come  to  Carlsbad  usually  in  the  period  of  latency; 
the  minority  still  have  coOcs  or  inflammation  of  the  gall-bladder. 
Now  begins  the  regular  living,  the  beneficial,  pain-assuaging,  laxative 
action  of  the  Carlsbad  springs,  the  delightful  influence  of  the  Sprudel 
baths  with  their  peat  poultices  to  the  liver  and  region  of  the  gall- 
bladder. The  beautiful  surroundings"  he  proceeds  ''entice  the  cure- 
guest  into  the  noble  forest,  he  climbs  the  mountains,  which  in  stillness 
leave  nothing  to  wish  for,  and  he  forgets  the  worry  of  his  business  and 
the  pain  of  his  disease.  The  cuisine  permitted  by  the  cure  removes  the 
sins  of  his  club  hfe  at  home,  of  the  many  strawberry  and  peach  punches; 
briefly,  the  tissue  changes  are  powerfully  stimulated,  and  whoever  is  not 
very  sick  must  in  a  very  short  time  indeed  feel  himself  well."  But 
while  such  a  life  is  a  patient's  privilege  if  he  can  aft'ord  it,  there  are  very 
many  who  cannot,  and  it  is  the  duty  of  the  attending  physician  to 
inform  his  patients  that  modern  surgery  offers  a  rapid  and  a  lasting 
cure  at  a  very  trifling  risk,  provided  operation  is  undertaken  before 
complications  have  arisen.  The  best  time  for  a  Carlsbad  "cure"  is 
after  operation. 

In  uncomplicated  cases  the  mortality  of  operation  is  less  than  5  per 
cent.,  and  in  the  hands  of  those  who  have  much  experience  in  this  work 
it  has  been  reduced  as  low  as  2  or  even  i  per  cent.  When  complications 
develop,  the  mortality  rises  rapidly,  as  will  be  noted  on  subsequent 
pages.  Not  only  is  the  migration  of  calcuh  from  the  gall-bladder  into 
the  duct  a  factor  of  very  serious  moment  in  increasing  the  death-rate 
from  cholelithiasis,  but  even  when  the  stones  remain  in  the  gall-bladder 
the  occurrence  of  acute  cholecystitis  or  its  possible  sequels,  such  as  peri- 
cholecystic  adhesions,  perforation  or  gangrene,  may  put  the  patient's, 
life  in  jeopardy  at  any  time.  The  safest  course,  by  far,  for  the  patient 
to  pursue  is  to  have  his  gall-stones  removed  as  soon  as  they  begin  to 
produce  noticeable  symptoms.  At  this  time  the  removal  of  the  calculi 
with  the  simple  operation  of  drainage  of  the  gall-bladder,  or  of  chole- 
cystectomy, will  eft'ect  a  cure.  Later  not  only  will  cholecystectomy 
be  necessary,  and  a  more  serious  undertaking  than  in  the  early 
stages  of  disease,  but  incision  and  drainage  of.  the  common  duct 
or  even  of  the  hepatic  duct  ma}'  be  required.  These  operations, 
and  others  yet  more  complicated,  have  a  much  higher  mortaUty,  and 
often  gravely  tax  the  technical  skill  as  well  as  the  Judgment  of  the 
surgeon.  We  believe  there  is  no  more  difficult  surgery  than  that  of  the 
bile-ducts. 

The  comparative  mortality  of  operations  for  these  various  condi- 
tions mav  be  seen  in  the  following  table: 


TREATMENT    OF    CHOLELITHIASIS 


497 


Operations  tor  Cholelithiasis  (191 2-1920) 
(Statistics  from  the  Lankenau  Hospitall 


Lesions 


Operations 

Deaths 

Mortality 
per  cent. 

628 

42 

6.7 

37 

2 

S-6 

23 

I 

43 

2 

0 

7 

3 

43  0 

I 

0 

8 

3 

37-5 

3 

2 

66.0 

46 

2 

4  3 

40 

I 

2-5 

7 

2 

28.5 

0 

804 

58 

7,0 

Without  Acute  infection' 

With:  Acute  cholecystitis 

Empyema 

Hydrops 

Gangrene  or  perforation. . 

Pericholecystic  abscess . . . . 

Acute  pancreatitis 

.\cute  cholangeitis 

Chronic  pancreatitis 

Pancreatic  lymphangeitis. 

Ulcer,  duodenal 

Ulcer,  gastric 


'  Including  calculi  in  the  common  and  hepatic  ducts. 

Recurrence  of  gall-stones  after  operation  is  exceedingly  rare. 
Although,  as  noted  at  page  423,  calculi  occasionally  have  formed  around 
a  silk  suture  or  other  foreign  material  left  in  the  gall-bladder  at  opera- 
tion, usually  "recurrence"  implies  not  a  new  formation  of  stones, 
but  that  some  calculi  were  overlooked  at  the  time  of  operation.  If 
operation  is  undertaken  at  the  propitious  time,  that  is,  before  any 
calculi  have  left  the  gall-bladder,  and  before  pericholecystic  adhesions 
have  developed  as  the  result  of  attacks  of  cholecystitis,  then  the  com- 
plete removal  of  the  calculi  is  not  difficult,  and  no  stones  should  be 
overlooked.  This  is  a  great  argument  in  favor  of  early  operation. 
Maurice  Richardson  reported  a  case  in  which,  after  dislodging  a  stone 
from  the  common  duct,  it  escaped  into  the  hepatic  duct;  and  he  found 
himself  absolutely  impotent  to  find  it  again:  "there  was  the  patient 
with  his  common  duct  wide  open,  and  somewhere  in  the  depths 
of  the  liver  was  the  offending  stone,  ready  to  be  drifted  down  into 
the  same  impaction  as  before."  Fortunately  such  a  catastrophe 
seldom  occurs,  even  to  surgeons  of  less  skill  and  experience  than 
Richardson. 

Robson  calls  attention  to  the  fact  that  in  the  very  large  experience 
of  Mayo,  Kehr,  and  himself,  it  had  been  stated  by  each  separately 
that  the  recurrence  of  gall-stones  after  cholecystostomy  was  an  ex- 
tremely rare  event.  In  191 1  W.  J.  Mayo  stated  that  among  4000 
operations  performed  upon  the  biliary  tract  by  himself  and  C.  H.  Mayo 


498  SURGERY    OF    THE    GALL-BLADDER    AND    BILE-DUCTS 

only  three  cases  were  observed  in  which  stones  had  reformed  in  the 
gall-bladder. 

But  while  this  freedom  from  recurrence  is  the  rule,  a  candid  state- 
ment of  fact  must  be  made  that  very  occasionally  true  recurrences 
of  gall-stones  (not  cases  of  overlooked  stones)  do  occur.  We  have 
encountered  a  few  such  cases  ourselves.  The  following  history  show- 
ing that  not  ver}'  many  months  after  the  senior  author  had  removed 
ICO  calculi  from  a  patient's  gall-bladder  another  surgeon  removed 
over  200  stones  from  it,  is  incontrovertible  proof  of  recurrence.  Two 
hundred  calculi  could  not  have  been  overlooked  at  the  first  operation. 

Miss ,  nurse,  operated  on  at  the  German  Hospital  in  1897  for  calculous 

cholecystitis,  removal  of  100  gall-stones.  Remained  perfectly  well  for  one  year 
when  she  had  a  recurrence  of  cholecystitis  and  subsequent  operation  with  removal 
of  200  stones. 

The  thing  which  demands  elucidation  is  not  why  recurrences 
occur,  but  why  they  do  not  occur  more  often.  True,  these  patients 
when  operated  upon  have  passed  the  age  during  which  infectious 
diseases  such  as  typhoid  fever,  entero-colitis,  etc.,  are  prone  to  occur. 
When  they  are  relieved  of  their  calculi  and  the  existing  infection  of 
the  bile-tract  is  cured  by  drainage  it  may  be  argued  that  no  renewed 
infection  of  the  biliary  tract  is  likely  to  develop,  because  these  pre- 
disposing causes  of  biliary  infection  will  not  again  arise.  Yet  such 
renewed  infections  occasionally  do  occur.  They  are  extremely  rare, 
however,  and  would  be  rarer  still  we  believe  were  cholecystectomy 
more  often  employed  in  cases  of  simple  cholelithiasis;  or,  if  the  gall- 
bladder is  not  removed,  were  postoperative  drainage  of  the  gall- 
bladder maintained  for  a  longer  time  than  often  is  the  case. 

But  though  early  operation  is  the  best  treatment,  in  cases  of 
simple  cholcUlhiasis  it  may  be  ver}-  difficult  to  persuade  the  patient 
to  submit  to  operation.  If  he  has  had  no  acute  attacks,  either  of 
cholec3'stitis  or  gall-stone  colic,  and  if  he  suffers  merely  from  symp- 
toms of  "indigestion,"  he  may  be  quite  satisfied  to  stay  as  he  is; 
and  a  surgeon  must  feel  xevy  sure  of  his  ground  before  attempting 
to  convince  such  a  patient  against  his  will.  Of  course  one  must 
bear  in  mind  the  slight  but  seemingly  unavoidable  mortality  which 
attends  any  large  series  of  operations.  An  occasional  death  will 
occur  from  pneumonia,  following  the  anesthetic.  But  as  Kehr  says, 
^'the  slight  dangers  of  early  0  per  at  ion  stand  in  no  sort  of  a  relation  with 
the  great  dangers  of  the  disease  itself Even  the  latent  chole- 
lithiasis we  should  always  regard  with  suspicious  eyes,  for  the  quiet 


TREATMENT    OF    CHOLELITHIASIS  499 

work  of  gall-stones  is  often  the  most  destructive."  Carcinoma  may 
develop  from  stones  which  cause  no  particular  distress;  and  perfora- 
tions into  hollow  viscera  (internal  biliary  fistula;,  page  525)  often 
occur  without  producing  any  acute  symptoms.  "The  danger  of 
carcinoma  alone,"  writes  Mayo,  "  is  five  times  as  great  as  is  the  mortal- 
ity following  operations  for  the  relief  of  simple  gall-stone  disease." 
"In  malignancy  and  insidioitsness,"  concludes  Kehr,  "no  disease  of 
man  compares  with  cholelithiasis." 

Yet  operation  is  not  to  be  insisted  upon  indiscriminately  in  every 
case.  The  contra-indications  to  operation  may  be  summarized  as 
serious  organic  lesions  of  the  heart,  lungs,  or  kidneys;  extreme  age; 
anemia  and  slow  coagulabihty  of  the  blood.  Such  patients  as  these 
must  lead  an  invalid's  life  and  may  hope  by  careful  dieting  and 
attention  to  hygiene  to  prevent  the  development  of  acute  complications 
which  will  render  operation  imperative  at  all  hazards. 

What  the  type  of  operation  shall  be  in  these  interval  cases  is  a 
subject  that  has  been  discussed  in  recent  years  a  little  too  strenu- 
ously. Certain  surgeons  contend  that  in  every  case  the  gall-bladder 
should  be  removed.  They  regard  it  as  a  hotbed  of  infection,  and 
claim  that  its  retention  favors  reformation  of  calcuH.  They  dwell 
upon  the  supposed  functional  uselessness  of  the  gall-bladder,  and 
upon  its  pathological  importance.  They  magnify  the  frequency  of 
persistent  fistulae,  or  reformation  of  calculi  and  recurrent  cholecystitis. 
But  it  is  well  known  that  calcuh  have  developed  in  a  dilated  common 
duct  after  cholecystectomy  (Mayo  has  observed  five  such  cases); 
and  the- danger  of  fistula  persisting  after  cholecystostomy  is  not  great 
if  no  obstruction  of  the  ducts  remains. 

A  further  argument  in  favor  of  retention  of  the  gall-bladder  unless 
functionally  useless  is  that,  should  a  subsequent  operation  be  required, 
the  gall-bladder  is,  as  stated  by  Hartmann,  not  only  the  thread  of 
Adriadne  which  guides  us  through  a  labyrinth  of  adhesions  to  the 
position  of  the  bile-ducts,  but  may  become  a  very  important  feature 
in  the  restoration  of  intestinal  drainage  of  bile,  by  means  of  chole- 
cystenterostomy,  in  cases  where  the  common  bile-duct  is  permanently 
obstructed.  The  argument  used  by  the  advocates  of  indiscriminate 
cholecystectomy  in  this  connection  is  not  valid.  They  assert  that 
if  the  gall-bladder  had  been  removed  at  the  first  operation  no  secondary 
operation  for  recurrence  of  symptoms  would  be  required.  Such  has 
not  been  our  own  experience,  and  we  agree  with  Richardson  that 
cholecystectomy  often  is  a  difficult  and  dangerous  operation — more 
difficult  and  dangerous  in  fact  than  a  simple  choledochotomy,  were 


500  SURGERY    OF    THE    GALL-BL.\DDER   AND   BILE-DUCTS 

the  latter  operation  done  in  cases  free  from  pathological  adhesions 
and  in  patients  not  gravely  ill  with  cholemia.  The  adhesions  which 
form  after  some  cholecystectomies  cause  more  trouble  than  the  original 
disease. 

We  believe  cholecystectomy  is  indicated  in  cases  of  simple  chole- 
lithiasis whenever  the  gall-bladder  presents  any  gross  evidence  of 
disease.  When  acute  calculous  cholecystitis  (page  503)  is  present 
cholecystectomj'  always  is  preferable  to  cholecystostomy;  except  in 
cases  in  which  only  the  slightest  operative  intervention  will  be  tolerated. 
When  as  the  result  of  repeated  attacks  of  acute  cholecystitis,  or  from 
the  long  duration  of  the  disease  in  a  latent  stage,  the  gall-bladder  is 
much  contracted  upon  its  contained  calculi,  removal  of  these  and  drain- 
age of  the  gall-bladder  even  if  prolonged  seldom  will  restore  to  it  a 
sufficient  degree  of  functional  activity.  In  such  cases  we  prefer  to  do 
cholecystectomy  at  once;  but  we  recognize  it  as  a  more  serious  pro- 
cedure, and  if  the  patient's  condition  is  unfavorable,  and  in  the  case 
of  very  fat  patients,  where  the  operation  is  one  of  unusual  difficulty, 
we  still  practice  the  simpler  operation  of  cholecystostomy.  Should 
further  trouble  occur  it  may  be  necessary  to  remove  the  gall-bladder 
then;  but  at  all  events  we  hold  it  is  better  for  the  patient  to  submit  to 
two  operations  and  live  to  tell  the  tale  than  to  perish  from  the  firsL  It 
is  in  such  cases  as  these  that  cholecystectomy  is  the  difficult  and  danger- 
ous operation  to  which  Richardson  refers;  but  desperate  diseases  require 
desperate  remedies,  and  when  disabling  symptoms  persist  the  gall- 
bladder must  be  removed. 

Cholecystectomy  we  see.  then,  is  not  indicated  in  cases  of  simple 
cholelithiasis  with  no  gross  pathological  changes  in  the  gall-bladder:  in 
cases  which  present  evidences  of  past  attacks  of  acute  cholecystitis, 
and  in  cases  with  pericholecystic  adhesions  removal  of  the  gall-bladder 
is  indicated  when  operation  is  done  in  the  interval,  unless  the  constitu- 
tional condition  of  the  patient  forbids.  It  is  indicated,  as  we  shall 
point  out  further  on:  (i )  in  most  cases  of  acute  calculous  cholecystitis,  as 
well  as  in  (2)  hydrops  with  obliteration  of  the  cystic  duct,  (3)  chronic 
empyema,  (4)  calcareous  degeneration.  (5)  the  cholesterin  gall-bladder  of 
Moynihan  and  the  strawberry  gall-bladder  of  MacCarty,  (6)  gangrene 
of  the  gall-bladder,  (j)  carcinoma,  and  (8)  in  most  cases  of  perforation. 

Treatment  of  Biliary  Colic. — In  many  cases  the  pain  is  not  so  severe 
but  that  it  will  be  relieved  by  local  application  of  an  ice  bag,  rest  in  the  re- 
cumbent position,  and  abstinence  from  all  food.  Nausea  may  be  relieved 
by  inducing  vomiting  by  drinking  a  couple  of  glasses  of  hot  water.  If 
retching  persists,  lavage  of  the  stomach  may  be  necessary.     Should  the 


TREATMENT  OF  STONE  IN  THE  COMMON  DUCT  501 

pain  be  great,  there  is  no  reason  wliy  morphin  should  not  be  adminis- 
tered hypodermically;  but  before  this  is  done  the  surgeon  should  be 
very  sure  of  his  diagnosis.  If  there  is  a  perforation  of  the  stomach 
or  duodenum,  instead  of  an  attack  of  biliary  colic,  immediate  opera- 
tion will  be  more  effective  in  allaying  pain  than  many  hypodermic 
injections. 

When  the  attack  of  bihary  colic  subsides,  the  matter  of  operation 
should  be  put  before  the  patient,  and  he  should  be  urged  to  submit  to 
having  his  gall-bladder  drained  or  removed  as  the  surest  means  of 
preventing  a  return  of  his  cohc. 

Treatment  of  Stone  in  the  Cystic  Duct. — The  operation  of  choice  is 
cholecystectomy.  In  these  cases  the  stone  almost  always  will  be  found 
to  have  caused  ulceration,  which  will  render  very  probable  the  subse- 
quent occurrence  of  stricture.  If  the  gall-bladder  and  cystic  duct  are 
not  removed,  perforation  at  the  site  of  impaction  in  the  cystic  duct  may 
occur  subsequently,  and  in  spite  of  free  drainage  of  bile  from  the  gall- 
bladder. Where  the  duct  appears  to  be  permanently  occluded,  as  in 
cases  of  hydrops  and  chronic  empyema,  then  also  the  gall-bladder  and 
cystic  duct  should  be  removed. 

Treatment  of  Stone  in  the  Common  Duct. — It  has  long  been  con- 
sidered unwise  to  operate  when  there  is  acute  obstruction  of  the  com- 
mon duct;  it  is  the  opinion  of  the  majority  of  surgeons,  in  this  country 
at  least,  that  it  is  better  to  tide  the  patient  over  the  attack  under  medical 
treatment  than  to  subject  him.  to  the  danger  of  an  operation  when  so 
acutely  ill.  In  Mayo's  hands  the  mortality  of  operation  in  such  cases- 
was  nearly  25  per  cent.  In  all  these  cases  of  obstructive  jaundice  from 
impaction  of  stone  there  are  times  when  some  bile  filters  through  and 
can  be  detected  in  the  feces  by  appropriate  tests.  If  the  patient  has 
been  carried  successfully  through  the  stage  of  complete  obstruction,  he 
should  be  subjected  to  operation  just  so  soon  as  the  stage  of  incomplete 
obstruction  is  reached.  Delay  then  certainly  is  more  perilous  than 
operation,  though  even  in  such  cases,  where  acute  cholangeitis  persists, 
but  where  complete  obstruction  is  not  present,  the  mortality  is  about 
10  per  cent. 

Treatment  during  the  persistence  of  acute  obstruction  is  the  same 
as  that  advised  for  biliary  colic:  nothing  by  mouth;  lavage  for  nausea 
and  vomiting;  local  appUcations  (ice  bag)  for  pain;  morphin  for 
unendurable  pain  (which  is  rare) ;  and  proctoclysis  of  normal  salt 
solution  or  tap  water  until  the  stomach  becomes  retentive  and  normal 
persistalsis  is  restored.  Operation  during  complete  obstruction  may- 
be   forced    upon    the    surgeon    sometimes   by    signs   of   perforation; 


502  SX'RGERY    OF    THE    GALL-BLADDER    AND    BILE-DUCTS 

but  few  such  patients  will  be  rescued.  Operation  should  not  be  done 
during  the  existence  of  spreading  peritontis;  it  should  be  postponed 
until  the  process  has  become  locaHzed. 

But  though,  as  we  have  said,  the  majority  of  surgeons  still  hold 
to  this  teaching,  we  have  been  forced  by  our  own  experience  to  the 
conclusion  that  in  the  long  run  immediate  operation  during  an  attack  of 
acute  obstruction  of  the  common  duct  is  attended  by  less  danger  than  is 
delay.  If  operation  is  delayed  the  patient  runs  the  risks  of  cholangeitis, 
cholemia,  with  the  gravest  form  of  sepsis;  not  to  mention  perforation  of 
the  common  duct  or  the  formation  of  almost  inoperable  adhesions;  or 
the  indefinite  persistence  of  chronic  jaundice  with  its  dangerous  hem- 
orrhagic tendencies. 

Our  experience  with  immediate  operation  is  so  far  too  limited 
for  us  to  be  willing  to  erect  this  as  a  rule  of  practice,  but  while  many 
times  there  has  been  cause  to  regret  not  operating  during  the  stage  of 
acute  obstruction,  never  yet  has  there  been  cause  to  regret  prompt 
relief  of  the  obstruction  by  operation. 

The  operation  of  choice  consists  in  choledochotomy,  removal 
of  the  stones  (which  involves  thorough  exploration  of  the  common 
and  hepatic  as  well  as  of  the  cystic  duct),  and  drainage  of  the  common 
duct  and  of  the  gall-bladder  by  separate  tubes.  Occasionally  the  gall- 
bladder has  to  be  removed;  but  it  should  be  left  unless  grossly  diseased, 
since  should  stricture  of  the  choledochus  subsequently  develop,  chole- 
cystenterostomy  may  be  required. 

Choledochotomy  for  the  removal  of  a  calculus  was  first  done  by 
Kiimmel  in  1S90.  It  was  studied  at  length  by  Terrier  in  1892;  he 
distinguished  between  the  operation  done  for  this  purpose  ("chole- 
dochotomie  proprement  dite")  and  that  done  for  drainage  in  cases  of 
cholangeitis  ("choledochostomie").  Parkes  in  1885  had  proposed  the 
operation.  Langenbuch  in  1884  had  suggested  removal  of  a  calculus 
impacted  in  the  retroduodenal  portion  of  the  choledochus  by  an  ap- 
proach through  the  transverse  mesocolon  near  the  hepatic  flexure  of  the 
colon.  Vautrin,  in  1896,  reported  three  cases  in  which  he  had  employed 
mobilization  of  the  duodenum  to  facilitate  retroduodenal  choledoch- 
otomy; the  descending  duodenum  was  loosened  from  the  posterior 
abdominal  wall  and  turned  to  the  p.-tient's  left.  The  idea  of  this 
manceuver  appears  to  have  originated  with  Terrier.  Haasler  introduced 
the  suggestion  into  Germany  in  1898,  and  it  was  finally  appropriated 
and  systematized  by  Kocher  in  1903,  in  connection  with  his  operation 
of  gastroduodenostom>-.  Transduodenal  choledochotomy  to  remove  a 
stone  near  the  ampulla  of  \'atcr,  proposed  in  1884  b}'  Langenbuch,  was 


TREATMENT  OF  ACUTE  CALCULOUS  CHOLECYSTITIS       503 

first  adopted  by  McBurney  in  1891.  Kocher  in  1894  performed  a 
somewhat  similar  operation,  which  he  named  transduodenal  chole- 
dochostomy,  as  he  sutured  his  choledochus  incision  to  the  incision  in  the 
posterior  duodenal  wall.  BibUographical  references  to  all  these  early 
operations  were  collected  with  great  care  by  Terrier  in  1892. 

Hepaticotomy  is  the  proper  term  for  the  operation  of  opening  the 
hepatic  duct;  and  hepaticoslomy  is  often  used  as  an  equivalent  term 
with  hcpaticus  drainage  known  also  as  Kehr's  operation  (1897),  though 
employed  as  early  as  1889  by  Abbe,  whose  patient  was  still  in  good 
health  when  the  operation  was  recorded,  in  1893. 

Hepatotomy,  for  removal  of  calculi  embedded  in  the  substance 
of  the  liver,  was  employed  in  1887  by  Knowsley  Thornton. 

The  technique  of  exposure  of  the  various  parts  of  the  common 
duct  and  removal  of  calculi  by  choledochotomy  is  described  in  Chapter 
XXIV.  If  possible  the  calculus  should  be  pushed  into  the  most  acces- 
sible portion  of  the  common  duct,  which  is  then  incised  directly  on  the 
calculus.  Sometimes,  as  urged  by  Kuhn  (1901),  it  is  possible  to  work 
the  calculus  back  into  the  gall-bladder  if  the  cystic  duct  is  dilated,  and 
thus  the  necessity  for  opening  the  common  duct  may  be  obviated. 
When  the  common  duct  has  been  opened  it  is  our  custom,  and  we  be- 
lieve it  of  much  importance,  always  to  make  sure  that  the  duct  is  patent 
throughout  by  passing  a  sound  through  it  into  the  duodenum,  as  in- 
sisted upon  so  strongly  by  Terrier.^  Until  this  can  be  done  the  surgeon 
should  not  be  satisfied  that  he  has  removed  every  cause  of  obstruction. 
Since  adopting  this  practice  we  are  quite  sure  that  exceedingly  few  cal- 
culi in  the  common  duct  have  been  overlooked. 

Drainage  in  these  cases  should  be  prolonged.  From  four  to  sLx 
weeks  at  the  least  should  elapse  before  the  bihary  fistula  is  allowed  to 
close;  but  it  often  is  difficult  and  sometimes  impossible  to  keep  it  open 
so  long.  It  is  too  early  closure  of  the  fistula  that  is  chiefly  responsible 
for  recurrence  of  cholecystitis  and  cholangeitis  after  operation. 

Treatment  of  Acute  Calculous  Cholecystitis. — As  intimated  al- 
ready, we  have  been  forced  to  the  conclusion  that  cholecystectomy 
is  preferable  to  cholecystostomj  in  most  cases  of  this  nature.  Though 
in  cases  of  cholelithiasis  where  there  never  has  been  an  attack  of  acute 
cholecystitis,  cure  without  fear  of  recurrence  may  be  secured  in  many 
cases  by  cholecystostomy,  this  is  not  true  of  the  gall-bladder  which  is 
acutely  inflamed.  If  prompt  operation  (within  forty-eight  hours  of 
the   commencement   of  the   attack)  is  undertaken  in  cases  of  acute 

'  Terrier  pointed  out  that  this  "catheterism"  of  the  biliary  passages  was  first  adopted 
in  1743,  by  J.  L.  Petit,  in  a  case  of  external  biliary  fistula. 


504 


SURGERY    OF    THE    GALL-BLADDER   AND   BILE-DUCTS 


Statistics  of  Cholecystostomy  for  Various  Lesions  (Lankenau  Hospital) 

1912-1920 


Lesions  of  the  bile  tract 


Died 


Abscess,  liver 

Calculus,  biliary   

Carcinoma,  gallbladder. 

Carcinoma,  gallbladder,  chronic  pancreatitis. . 

Cirrhosis  liver,  cholangitis 

Cholecystitis,  acute 

Cholecystitis,  acute,  calculus. 
Cholecystitis,  acute,  perforated,  calculus.  . 
Cholecystitis,  acute,  calculus,  cholangitis. 

Cholecystitis,  chronic 

Cholecystitis  chronic,  pancreatitis,  acute. 
Cholecystitis  chronic,  pancreatitis  chronic. 
Cholecystitis  chronic,  pancreatic  lymphangitis. 

Cyst,  Hver 

Empyema 

Empyema,  calculus. 

Hydrops,  calculus 

Obstruction,  common  duct,  acute. , 

Pancreatic  lymphangitis 

Pancreatic  lymphangitis,  calculus. 

Pancreatitis,  acute,  calculus 

Pancreatitis  acute,  cholangitis 
Pancreatitis  chronic,  calculus.  . 
Pancreatitis  chronic,  pancreatic  lymphangitis 


Cholecystostomy  &  dochostomy  (See  dochostomy). 


I 

I 

2 

0 

17 

0 

I 

0 

2 

0 

0 

I 

0 

4 

I 

S 

0 

3 

16 
3 

208 
34 


12  (S-76%) 
3  (8.8%) 


Total I  242  IS  (6. 

Statistics  of  Cholecystectomy  for  Various  Lesions  (Lankenau  Hospital) 

Igi2-IQ20 


Lesions  of  the  bile  tract 

Calculus 

Calculus,  obstruction,  common  duct,  cholangitis 

Carcinoma,  gallbladder 

Carcinoma  pancreas,  calculus. 

Cholecystitis,  acute 

Cholecystitis,  acute,  calculus 

Cholecystitis,  acute,  perforation,  calculus 

Cholecystitis,  chronic 

Cholecystitis,  chronic,  cholangitis,  hepatitis. . . 

Cholecystitis  chronic,  carcinoma  ileum 

Cholecystitis,  chronic,  pancreatic  lymphangitis 

Cljolecystitis,  chronic,  pancreatitis  chronic . 

Cholecystitis,  chronic,  pancreatitis  chronic,  pancreatic  lymphangi- 
tis      

Cholecystitis,  chronic,  pancreatitis  chronic,  cirrhosis  liver. 

Cholecystitis,  chronic,  papilloma,  gallbladder 

Empyema 

Empyema,  calculus. . . 

Fistula 

Hydrops 

Pancreatic  lymphangitis,  calculus. 

Pancreatitis,  acute,  calculus 

Pancreatitis,  chronic,  calculus 

Pancreatitis,  chronic,  pancreatic  lynijjhangitis 


Cholecystectomy  &  dochostomy  (See  dochostomy). 
Total 


412 


1 1 

32 

4 

280 

1 


26 


6 

I 

17 

I 

6 

I 

S 

0 

40 

t 

S 

I 

9 

I 

6 

0 

862 

S8  16  7%) 

154 

II  (6.7%) 

1026 

60  (6  7%) 

OPERATIONS   FOE    CHOLELITHIASIS 


505 


Statistics  of  Choledochostomy  for  Various  Lesicns  (Lankenau  Hospital) 

IQI2-IQ20 


Choledochostomy  &  Cholecystostomv 

Calculus 

Cirrhosis  liver,  cholangitis,  calculus 

Cholecystitis,  chronic 

Pancreatitis,  chronic 

Pancreatitis,  chronic,  calculus 
Pancreatic  lymphangitis,  calculus 
Obstruction,  common  duct,  acute,  . 


Choledochostomy  Total 


Lesions  of  the  bile  tract 

Cases 

Died 

Calculus.  . 

13 

4 

Cholangitis 

I 

0 

Cirrhosis,  liver,  acute  pancreatitis. 

I 

0 

Cirrhosis,  liver,  calculus.  . 

I 

0 

Pancreatitis,  chronic 

s 

I 

Pancreatitis,  chronic,  calculus. . 

8 

I 

Obstruction,  common  duct,  stricture, 

2 

0 

Obstruction  common  duct,  calculus                 , 

I 

0 

35 

6  (n.-i%) 

Choledochostomy  &  Cholecystectomy 

Calculus 

86 

6 

Calculus,  pancreatic  lymphangitis.    , 

.  II 

0 

Calculus,  cholangitis,  acute 

0 

Calculus,  common  duct  obstruction. 

I 

0 

Cholecystitis,  acute 

0 

Cholecystitis,  acute,  calculus,  cholangitis. 

0 

Cholecystitis,  chronic 

12 

I 

Cholecystitis,  chronic,  pancreatitis  chronic 

0 

Empyema,  calculus 

0 

Fistula 

0 

Fistula,  empyema 

0 

Fistula,  chronic  cholecystitis. 

0 

Stricture,  common  duct 

0 

Pancreatic  lymphangitis 

0 

Pancreatitis,  acute 

2 

0 

Pancreatitis,  acute  (abscess),  calculus 

I 

I 

Pancreatitis,  chronic 

32 

2 

164 

11    (6.7%) 

3  (8.8%) 
20  (.8.6%) 


Statistics  of  Cholfcystenterostomy  for  Various  Lesions  (Lankenau  Hospital) 

1912-1Q20 

Cholecystoduodenostomv  I  I 

Carcinoma  pancreas 

Cyst,  pancreas.  ,  ,      . 

Pancreatitis,  chrome 

Pancreatitis,  chronic,  calculus 

Pancreatitis,  chronic,  cholecystitis,  chronic.  - 
Pancreatitis,  chronic,  cirrhosis  liver,  duodenal  ulcer 

Cholecystoduodenostomv  &  Choledochostomy 
Carcinoma,  pancreas 

Hep.\ticoduodenostomy 
Pancreatitis,    chronic' 


19 


2  (10.5%) 


I  See  Case  History,  p.  518. 


5o6  SURGERY   OF    THE    GALL-BLADDER    AND   BILE-DUCTS 

cholecystitis,  the  gall-bladder  and  ducts  are  free  from  adhesions,  and 
cholecystectomy  by  the  typical  technique  is  an  easy  operation.  Subperi- 
toneal enucleation  may  be  accomplished,  after  division  of  the  cystic 
duct  and  ligation  of  the  cystic  artery;  and  the  peritoneal  flaps  which 
remain,  effectually  cover  in  the  bed  of  the  gall-bladder  on  the  under 
surface  of  the  Uver.  This  complete  peritonization  of  denuded  surfaces 
prevents  the  development  of  adhesions,  which  are  almost  unavoidable 
when  removal  of  the  gall-bladder  is  delayed  until  after  the  patient  has 
had  several  attacks  of  acute  cholecystitis.  In  such  cases  pericholecystic 
adhesions  already  exist,  and  though  the  gall-bladder  may  require 
removal  because  no  longer  functionallj-  useful,  the  operation  is  much 
more  difficult  and  the  mortahty  is  much  higher  than  when  cholecystec- 
tomy is  done  early  in  the  first  attack  of  cholecystitis.  The  benign 
character  of  the  operation  under  the  latter  circumstances  was  first 
well  demonstrated  byLeriche  and  Cotte  (1912). 

It  is  in  these  cases  of  acute  calculous  cholecystitis  that  we  find 
recurrence  of  symptoms,  if  not  indeed  new  formation  of  calcuH,  after 
the  operation  of  simple  drainage;  and  we  repeat  once  more  that  where- 
as in  cases  of  simple  choleHthiasis  cholecystostomy  is  sometimes  the 
operation  of  choice,  in  cases  of  acute  calculous  cholecystitis  cholecystec- 
tomy is  always  to  be  preferred. 

The  treatment  of  the  other  acute  compfications  of  cholelithiasis, 
such  as  perforation,  gangrene,  pericholecystic  abscess,  etc.,  is  the  same  as 
when  no  calcuH  are  present  (page  458). 

Obstruction  or  the  Biliary  Passages 

Obstruction  of  the  biliary  passages  is  of  very  common  occurrence. 
The  causes  maj'  be  classified  in  three  groups:  (i)  Obstruction  from 
within  the  ducts,  which  is  exemplified  almost  solely  by  the  lodgment  of 
bihary  calcuU,  although  rare  cases  of  obstruction  from  intestinal 
parasites  have  been  recorded.  (2)  Obstruction  from  changes  in  the 
walls  of  the  ducts,  which  are  due  chiefly  to  strictures  and  neoplasms, 
both  rather  unusual  causes  of  biliary  obstruction.  (3)  Obstruction 
from  pressure  of  neighboring  structures :  among  these  may  be  mentioned 
especially  pericholecystic  adhesion^,  pancreatic  lymphangeitis  and 
chronic  pancreatitis,  and  carcinoma  of  the  head  of  the  pancreas.  Other 
rarer  causes  of  biliary  obstruction  must  also  be  classified  here — such  as 
pyloric  tumors,  enlarged  lymph-nodes,  or  kinks  of  the  ducts  caused  by 
movable  kidney.  A  large  calculus  in  the  cystic  duct  may  by  its  pressure 
cause  obstruction  of  the  hepatic  and  common  ducts. 


STEICTXIRES    or    THE   BILE-DUCTS  507 

Biliary  obstruction  from  impaction  of  calculi  has  been  considered 
already:  the  pathology  of  the  condition  was  discussed  at  page  469,  and 
its  clinical  aspect  at  page  494. 

Strictures  of  the  Bile-ducts. — Congenital  obstruction  of  the  bile- 
passages  is  discussed  at  page  441.  Acquired  narrowing  and  occlusion 
of  the  bile-passages  varies  in  frequency  with  the  duct  under  considera- 
tion. Stricture  of  the  cystic  duct  is  not  uncommon;  that  of  the 
common  duct  is  rare;  while  stricture  of  the  hepatic  duct  is  almost 
unknown. 

The  cystic  duct  is  the  least  unusual  site  for  a  stricture.  This 
is  so  not  only  because  of  its  tortuosity,  but  because  it  is  the  commonest 
site  for  the  lodgment  of  a  calculus;  and  it  is  the  cicatrization  of  an 
ulcer,  the  result  of  the  passage  of  a  calculus,  which  is  the  usual  cause  of 
the  stricture. 

The  main  symptoms  presented  are  those  of  hydrops  of  the  gall- 
bladder (page  450),  or,  if  the  contents  of  the  gall-bladder  become  in- 
fected, of  suppurative  cholecystitis  or  empyema  of  the  gall-bladder 
(page  451) ;  and  treatment  is  that  suitable  for  these  conditions. 

Stricture  of  the  common  duct  generally  is  due  to  injury  by  the  pas- 
sage or  attempted  passage  of  a  gall-stone  or  is  the  result  of  a  previous 
operation.  It  is  possible  that  a  stricture  may  occur  as  a  complication 
or  sequel  either  of  typhoid  fever  or  syphilis. 

The  symptoms  of  stricture  of  the  common  duct  are  those  usually 
seen  in  cases  of  constant  obstruction  of  the  duct  (page  589),  notably 
jaundice  which  is  constant  and  increasing,  acholic  stools,  marked 
indigestion  with  nausea  and  emaciation.  In  the  absence  of  infection 
above  the  stricture  there  should  be  no  fever.  The  gall-bladder  may 
be  distended  and  palpable. 

Strictures  of  the  hepatic  duct  are  very  rare :  theoretically  the  lesion 
should  cause  the  same  symptoms  as  those  due  to  constant  obstruction 
of  the  common  duct,  with  the  exception  that  the  gall-bladder  will 
not  be  dilated.  Langenbuch  (1897)  referred  to  seven  cases  found  at 
autopsy.  The  senior  author  has  met  with  but  one  case,  occurring  in 
a  colleague.  The  operation  consisted  in  opening  the  common  duct 
and  gradual  dilatation  of  the  stricture.  The  patient  remains  well, 
now  five  years  after  the  operation. 

A  differential  diagnosis  between  stricture  of  the  common  duct 
and  other  forms  of  chronic  continuous  obstruction  of  the  common 
duct  cannot  be  made  with  any  degree  of  certainty;  nor  can  a  distinc- 
tion be  drawn  between  obstruction  of  the  common  duct  and  that  of  the 
hepatic,  except  by  the  absence  of  a  distended  gall-bladder  in  the  latter 


5o8 


SURGERY    OF    THE    GALL-BL.\DDER    AXD    BILE-DUCTS 


condition.     But  as  in  most  cases  of  cholelithiasis  the  gall-bladder  is 
contracted,  little  reliance  can  be  placed  on  this  sign. 

The  treatment  of  strictures  of  the  bile-duct  is  by  operation,  and  this 
should  not  be  delayed,  as  every  day  aggravates  the  patient's  condition. 

Two  indications  are  to  be  met: 
to  drain  temporarily  the  infected 
gall-bladder  and  hepatic  ducts,  and 
to  reestablish  a  channel  for  the 
excretion  of  the  bile.  It  was  the 
opinion  of  Mathieu  (1908),  to 
whose  excellent  monograph  on 
strictures  of  the  biliary  ducts 
every  student  of  this  subject  must 
refer,  that  the  former  indication 
can  be  attained  in  most  cases  by 
the  latter  means,  namely  by 
allowing  drainage  into  the  intes- 
tine, by  direct  treatment  of  the  stricture  or  even  by  cholecyst- 
enterostomy;  but  should  there  be  any  e\ddence,  even  the  slightest,  of 
active  cholangeitis,  the  surgeon  will  have  to  establish  independent 
drainage  either  by  cholecystostomy,  or  by  drainage  of  the  choledochus, 
or  the  hepaticus,  or  even  by  hepatostomy  (page  514). 


Fig.  143. — Diagram  to  Show  Parts  which 
must  be  Excised  in  a  Case  of  Stricture  at 
the  Hepatico-cystic  Juncture. 


Fig.  144.- 


-Resection  of  Choledochus,  Closure  of  both  Ends  and  Cholecysto-duodenostomy. 
(After  Kchr.) 


When  there  is  stricture  of  the  c\stic  duct,  with  resulting  hydrops 
or  empyema,  or  an  atrophied  condition  of  the  gall-bladder,  cholecystec- 
tomy is  the  proper  operation,  combined  in  many  cases  with  drainage 
of  the  common  duct.     When  the  obstruction   involves  the  hepati- 


STRICTURES    OF   THE   BILE-DUCTS  SO9 

cocystic  juncture,  cholecystectomy  must  be  supplemented  by  resection 
of  the  obstructed  portions  of  the  common  and  hepatic  ducts  (Fig.  143). 

When  the  stricture  is  in  the  common  duct  or  in  the  hepatic  duct, 
the  technique  of  the  operation  for  the  re-estabhshemnt  of  the  course 
of  the  bile  comprises:  (i)  Treatment  of  the  obstruction,  when  accessible, 
including  resection  or  incision  with  plastic  operation;  and  (2)  Restora- 
tion of  the  continuity  of  the  outlet,  which  may  comprise  end-to-end 
suture  of  the  divided  ends  of  the  duct,  or  anastomosis  of  the  upper 
segment  of  the  duct  with  the  intestine  and  exclusion  of  the  lower 
segment  of  the  duct. 

In  cases  where  the  gall-bladder  is  healthy  and  the  cystic  duct 
patulous,  we  beUeve  the  operation  of  choice  for  stricture  of  the  common 
duct  is  cholecystenterostomy  (page  515);  thus  bile  will  be  discharged 
into  the  intestine  in  spite  of  the  obstruction  of  the  common  duct. 

Choledocho plasty  of  the  supraduodenal  choledochus,  analogous  to 
pyloroplasty,  was  employed  successfully  by  Petersen  and  by  Moynihan, 
the  latter  employing  temporary  drainage  of  the  duct.  Stubenrauch 
(1906)  devised  a  series  of  plastic  operations  on  the  common  duct,  which 
are  ingenious,  but  scarcely  practicable.  In  one  case  he  used  with 
success  a  flap  from  the  stomach  to  replace  the  common  duct;  Kehr 
employed  a  similar  operation  without  success,  but  in  another  case 
succeeded  in  saving  his  patient's  life  by  employing  a  flap  from  the  gall- 
bladder. 

Resection  of  the  choledochus  seldom  has  been  dome.  Oppenheimer 
(191 2)  collected  eighteen  operations,  with  an  immediate  mortality  of 
50  per  cent.:  ten  operations  were  for  carcinoma,  with  six  deaths;  four 
for  cicatricial  stricture,  with  two  deaths;  three  for  calculus,  with  no 
deaths;  and  there  was  one  fatal  operation  for  benign  tumor.  Eliot 
(1917)  collected  23  cases  of  end-to-end  suture  of  the  common  bile-duct, 
4  of  which  were  failures.  There  were  ten  primary  sutures,  the  longest 
defect  being  5  cm.  (Kehr) ;  and  in  this  case  re-operation  was  required 
two  months  later  for  stricture.  There  were  thirteen  instances  of 
end-to-end  suture  after  resection  of  a  stricture,  and  in  these  the  longest 
defect  bridged  was  one  of  3  cm.  (Riggs),  the  patient  in  this  case  being 
in  good  health  four  years  and  a  half  later.  Although  an  attempt  at 
end-to-end  suture  should  always  be  made  in  these  cases,  generally  it  will 
be  sufficient  to  unite  the  posterior  wall  by  two  or  three  sutures,  and  leave 
a  drainage-tube  in  the  opening  in  the  anterior  wall.  A  T-drainage 
tube  is  useful  in  such  cases  (Fig.  145),  and  the  defect  in  the  choledochus 
should  be  covered  with  omentum.  This  supports  the  anastomosis, 
and  the  T-tube  allows  the  bile  to  be  discharged  both  into  the  duodenum 


5IO 


SURGERY    OF   THE    GALL-BLADDER   AND   BILE-DUCTS 


and  through  the  abdominal  wound.  When  granulations  have  had 
time  to  form,  in  the  course  of  three  to  live  weeks,  the  tube  is  removed 
through  the  abdominal  wound,  and  the  fistula  allowed  to  close.  IMuch 
more  complicated  methods  have  been  used  but  not  with  notably  better 
results. 

If  end-to-end  suture  of  the  resected  common  duct  cannot  be  ac- 
complished, the  ends  may  be  joined  by  a  T-tube  of  rubber,  and  the  gap 
reinforced  by  omentum,^  as  already  suggested;  or  Sullivan's  method 


Fig.  145. — After  Resection  of  Choledochus its  PostLTior  Wall  has  been  Unite. 1 1>\  Sutures 
and  a  T-drainage  Tube  Inserted.  {Cinsbiirg  and  Spcese.  Annuls  of  Surgery.  iQir.LXV, 
p.  So.  Fig.  2.) 


may  be  employed  (page  516).  But  if  the  obstruction  is  so  close  to  the 
duodenal  termination  of  the  duct  that  resection  cannot  be  done  the 
•duct  may  be  divided  above  the  stricture  and  its  proximal  end  implanted 
into  the  duodenum,  the  distal  end  being  closed  (Fig,  146).  This  opera- 
tion (cliolcdoclw-cnlcroslomy)  is  less  difficult  when  the  duct  has  become 
dilated  from  long-standing  back-pressure  from  a  subjacent  stricture 
than  in  ordinary  cases.     Termino-lateral  implantation,  suggested  by 

'  Construction  of  artificial  channels  for  the  bile,  by  means  of  omentoplasty,  was  studied 
experimentally  in  lyoi  by  Enderlen  and  Justi. 


STRICTURES    OF    THE   BILE-DUCTS 


511 


Czerny  in  1892, is  preferable  to  the  original  lateral  anastomosis  employed 
by  Riedel  in  1888.  If  only  the  hepaticus  is  available  for  the  anastomosis, 
he patico-enlcr ostomy  may  be  attempted;  it  is  advisable  in  such  cases  to 
resort  to  mobilization  of  the  duodenum,  and  to  fix  it  by  sutures  to  the 
liver  over  the  site  of  the  anastomosis.  Or,  as  already  mentioned  (p.  509) 
a  pedicled  flap  may  be  turned  up  from  the  gall-bladder,  the  stomach,  or 
from  the  duodenum  (Walton,  1915;  Ginsburg  and  Speese,  1917),  and 
used  to  construct  a  channel  for  the  bile  from  the  afferent  segment  of 


■W'- 


Fig.  146. — Choledocho-enterostomy.  After  Resaction  of  Choledochus  Low  Down, 
It  may  be  Possible  to  Suture  Its  Proximal  End  Directly  to  the  Duodenum.  (Ginsberg 
and  Speese,  in  Annals  of  Surgery.) 

the  bile  duct  into  the  gastro-intestinal  canal  (Fig.  147) ;  or  such  a  channel 
may  be  constructed  from  a  free  transplant  of  fascia  lata  (Fig.  148)  or 
even  by  means  of  a  rubber  tube  alone,  as  indicated   at  p.  515. 

In  the  first  edition  of  this  work  we  tabulated  42  operations  in  which 
an  anastomosis  was  made  between  the  afferent  stump  of  the  bile  duct 
and  the  gastro-intestinal  canal:  the  immediate  result  is  reported  in  all 
but  one  case,  there  being  30  recoveries  and  only  11  deaths;  but  a  num- 
ber of  patients  who  recovered  from  the  operation  subsequently  devel- 
oped recurrence  of  biliary  obstruction  and  all  were  not  relieved  by 
further  operation.     Guerry  (1918)  has  recently  reported  seven  direct 


iI2 


SURGERY   OF   THE    GALL-BLADDER    AND   BILE-DUCTS 


anastomoses  done  by  himself  between  the  common  bile  duct  and  the 
duodenum,  with  only  one  operative  death,  and  four  symptomatic  cures. 
The  subject  has  been  studied  experimentally  by  Barber  (1919). 

Some  anastomoses  have  also  been  made  between  dilated  biliary 
radicles  within  the  liver  substance  and  the  intestine;  this  operation  is 
known  as  hepatocholangeioenterostomy  (Fig.  149).  It  was  proposed  in 
1896  by  Baudouin,  and  in  1897  by  Langenbuch  and  Ulmann.  Mon- 
profit in  1904  suggested  the  propriety  of  using  a  jejunal  loop  in  Y.     Of 


Fig.  147. — Choledochoplasty.  A  Flap  is  Turned  up  from  the  Duodenum  and  Sutured 
to  the  Proximal  End  of  the  Choledochus  over  a  Rubber  Tube  as  a  Guide.  (Ginsburg 
and  Speese,  in  Annals  of  Surgery.) 

9  such  operations  tabulated  in  our  first  edition,  4  terminated  fatally 
after  short  intervals,  and  only  one  patient  is  known  to  have  survived 
more  than  a  few  months. 

Though  transduodenal  cliolcdochotomy  for  the  removal  of  gall-stones 
impacted  at  the  ampulla  of  Vater  has  been  done  on  numerous  occasions, 
only  a  few  such  operations  for  stricture  are  on  record  (Korte,  Oehler); 
and  excision  of  an  obstruction  at  this  point  seldom  has  been  done  except 
in  the  case  of  carcinomata  (page  590). 

While  some  form  of  cholecystenterostomy  often  is  a  very  successful 
operation,  the  same  cannot  be  said  of  the  other  procedures  mentioned, 
as  will  be  appreciated  by  consideration  of  the  statistics  already  given. 


STRICTURES    OF    THE    BILE-DUCTS  513 

But  in  view  of  the  extremely  poor  constitutional  condition  of  the  pati- 
ents, the  results  are  not  surprising;  and  the  surgeon  certainly  is  justified 
in  attempting  to  relieve  an  otherwise  hopeless  condition. 

Cholcdochostomy,  or  union  of  the  dilated  common  bile-duct  with 
the  abdominal  wound  has  been  done  in  a  few  rare  instances,  but  is  no 
longer  a  recognized  operation.  Usually  the  dilated  duct  ha^  been  mis- 
taken for  the  gall-bladder  itself.  The  term  cholcdochostomy  fre- 
quently is  used  synonymously  with  drainage  of  the  choledochus.     In 


„.„.»«*>r^aBfB^., 


Fig.   148. — Choledochoplasty  by  Means  of  a  Free  Transplant  of  Fascia  Lata.     (Ginshurg 
and  Speese.  in  Annals  of  Surgery.) 

the  earliest  operations  on  the  common  duct  an  attempt  always  was 
made  to  suture  the  incision  made  into  it  for  the  removal  of  a  calculus; 
but  this  was  soon  abandoned,  and  choledochus  drainage  is  now  an  opera- 
tion rather  frequently  performed  in  cases  of  cholangeitis,  or  after  re- 
moval of  a  calculus  by  choledochotomy.  References  to  the  early 
operations  on  the  common  duct  (by  Kiimmell,  in  1884;  by  Thornton 
and  by  Heusner,  in  1889  and  by  Courvoisier,  in  1890)  are  given  in 
Berger's  monograph.  Richter  and  Buchbinder  (1919)  urge  its  suture 
with  two  rows  of  the  very  finest  suture  material,  and  closure  of  the 
abdomen  without  drainage,  except  in  infected  cases;  and  they  report 


514 


SURGERY    OF    THE    GALL-BLADDER    AND    BILE-DUCTS 


that  in  only  one  out  of  eleven  consecutive  cases  of  choledochotomy  did 
they  employ  a  drain.  Halsted  (1920)  also  prefers  to  close  the  duct 
without  drainage. 

Hepatkoslomy,  or  suture  of  the  hepatic  duct  to  the  skin  for  the 
purpose  of  drainage  has  been  done  a  few  times  under  the  same  circum- 
stances in  which  choledochostomy  was  formerly  employed.  According 
to  Terrier,  it  was  first  done  in  18S9,  by  Kocher.  In  Bier's  patient  death 
occurred  in  seven  days.  In  a  patient  under  the  care  of  ISIayo  the  proxi- 
mal end  of  the  hepatic  duct  could  not  be  found  after  an  extensive  exci- 
sion for  carcinoma;  all  the  bile  was  discharged  by  the  wound,  and  death 


Fig.  149. — Diagram  of  Hepato-cholangeio-enterostomy.     {After  Kehr.) 

followed  at  the  end  of  nine  weeks.  In  the  somewhat  similar  case  of 
Kehr,  death  ensued  in  seven  days  from  cholemic  hemorrhage.  The 
term  hepaticostomy  sometimes  is  erroneously  used  as  synonjTnous  with 
hepaticus  drainage  which  is  known  also  as  Kehr's  operation  (1897).  It 
is  practised  quite  frequently  after  choledochotomy,  the  drainage  tube 
being  passed  upward  past  the  entrance  of  the  cystic  duct,  so  as  to  drain 
the  hepatic  duct  directly  (p.  780). 

Hepalostomy,  or  drainage  of  the  intrahepatic  bile-passages,  is 
indicated  only  when  all  the  extrahepatic  biliary  ducts  are  strictured 
or  occluded.  First  adopted  by  Sendler  (1895),  in  ^  case  of  suppurative 
cholangeitis,  it  was  advocated  by  W.  E.  B.  Davis  (1901)  and  by 
Haasler  (1904).  According  to  Berger  (1903)  this  operation  has  been 
done  by  Hirschberg,  whose  technique  consisted  in  performing  hepato- 
tomy  by  a  larger  trocar,  with  subsequent  dilatation  and  drainage  of 


STRICTURES    OF    THE   BILE-DUCTS  515 

this  channel.  In  some  patients  with  chronic  biliary  obstruction, 
the  dilated  intrahepatic  bile-channels  project  from  the  surface  of  the 
liver  in  the  form  of  small  cysts;  and  in  most  of  these  patients  greatly 
dilated  bile-spaces  may  be  found  close  to  the  surface  of  the  liver, 
even  if  they  are  not  visible  on  its  surface.  So  the  operation  is  not 
as  erratic  as  might  seem  to  be  the  case  at  first  thought.  But  the 
operation  known  as  hepatocholangeio-enterostomy  (Fig.  149)  should 
be  preferred,  when  practicable.  As  Mathieu  (1908)  well  says,  the 
operation  of  hepatostomy  is  not  one  of  choice,  but  is  comparable 
to  an  enterostomy  done  for  intestinal  obstruction  in  the  case  of  a 
patient  too  ill  to  endure  the  search  for  the  site  of  occlusion;  and, 
if  the  patient  survives,  a  secondary  operation  will  be  necessary  to 
restore  the  bile  to  the  intestinal  tract. 

Cholecystentcrostomy. — This  operation  was  introduced  in  1882 
by  von  Winiwarter,  who  made  the  anastomosis  with  the  colon 
(cholecysto-colostomy).  J.  McF.  Gaston  (1884)  and  W.  E.  B.  Davis 
(1901)  were  among  the  first  in  this  country  to  do  experimental  work  in 
connection  with  this  subject.  Until  recent  times  most  surgeons  have 
employed  the  duodenum  (cholecysto-duodenostomy) ;  but  the  operation 
of  cholecysto-gastrostomy  was  shown  experimentally  by  Oddi  (1888)  to 
be  well  tolerated  by  dogs  after  section  of  the  choledochus,  and  it  was 
adopted  in  man  first  by  Gersuny  (Wickhoff,  1893),  then  by  Terrier 
(1896)  as  he  found  that  the  presence  of  the  bile  in  the  stomach  pro- 
duced no  bad  effects,  and  the  anastomosis  with  the  stomach  usually 
was  easier  than  with  the  duodenum.  The  jejunum  may  be  used  instead 
of  the  duodenum,  as  was  done  in  former  years  not  infrequently;  but 
we  beUeve  the  advantages  of  cholecysto-gastrostomy  are  now  quite 
generally  recognized.  The  statistics  of  some  recent  cases  of  cholecyst- 
entcrostomy in  the  senior  author 's  service  at  the  Lankenau  Hospital 
have  been  given  at  p.  505. 

Eepatico-enterostomy  by  Means  of  a  Rubber  Tube. — When  the 
distal  end  of  the  choledochus  cannot  be  utilized  in  re-establishing 
the  normal  course  of  the  bile  it  becomes  necessary,  when  the  gall- 
bladder is  absent,  to  anastomose  the  proximal  stump  of  the  choledochus 
or  the  hepaticus  with  the  duodenum.  Occasionally  this  can  be  ac- 
complished directly  by  suture  (Fig.  146) ;  but  often  the  duodenum, 
even  after  it  has  been  mobilized,  cannot  be  brought  up  near  enough  to 
the  hepaticus  to  permit  of  this  method  being  employed.  The  use  of 
the  jejunum  in  such  circumstances  is  objectionable,  but  if  an  anasto- 
mosis can  be  made  with  the  stomach,  this  should  be  done.  Several 
surgeons  have  had  the  idea  of  reconstructing  a  channel  for  the  bile  from 


5i6 


SURGERY    OF    THE    GALL-BLADDER    AND   BILE-DUCTS 


the  liepaticus  stump  to  the  duodenum  or  stomach  by  means  of  a  rubber 
tube.  In  some  of  the  earlier. operations  it  was  thought  necessary  to 
withdraw  this  tube  through  the  abdominal  wound  before  this  was  per- 
mitted to  close.  Volleker's  technic  is  indicated  in  Fig.  150.  SulUvan. 
however,  working  with  Draper  Maury,  proved  by  experiments  on  dogs 
that  it  was  safe  to  leave  the  tube  in  place,  trusting  to  its  expulsion 
into  the  duodenum  and  its  final  discharge  from  the  rectum. 

The  plan  of  operation  adopted  by  Sullivan  (iqoq)  may  be  summar- 
ized as  follows:     The  tube  used  is  approximately  the  size  of  the  com- 


FiG.  150. — Voelcker's  Method  of    Choledocho-(hepatico)-duodenostomy    by  means  of  a 
Rubber  Tube  which  Emerges  from  the  Duodenum  through  a  Witzel  Fistula. 


mon  duct;  its  duodenal  end  is  tipped  with  a  rubber  or  marine  sponge 
not  larger  in  diameter  than  half  the  lumen  of  the  intestine.  The 
proximal  end  of  the  choledochus  or  hepaticus  is  freely  exposed,  and 
two  plain  catgut  sutures  are  introduced  into  one  end  of  the  tube,  on 
opposite  sides,  and  are  then  passed  through  the  wall  of  the  duct  from 
within  outward  so  as  to  draw  the  end  of  the  tube  into  the  open  end  of  the 
duct  when  the  sutures  are  drawn  taut.  The  tube  is  carried  into  the 
lumen  of  the  duct  about  one  centimetre.  The  other  end  of  the  tube, 
carrying  the  sponge,  is  then  implanted  into  the  anterior  wall  of  the 
duodenum  at  the  level  of  the  papilla  of  Vater  by  means  of  a  Witzel  fis- 
tula (page  319).     The  tube  itself  is  sutured  to  the  duodenum  at  one 


HEPATICO-ENTEROSTOMY 


517 


point  with  line  catgut  so  as  to  prevent  its  too  early  expulsion  into  the 
intestinal  canal.  The  great  omentum  is  then  drawn  up  and  a  suitable 
area  is  traumatized  lightly  with  gauze  friction;  similar  friction  is  applied 
to  the  duodenum  and  gastrohepatic  omentum  on  both  sides  of  the 
tube.  The  great  omentum  is  then  adjusted  so  as  to  cover  the  tube 
and  e.\tend  beyond  it  in  all  directions,  and  is  held  in  place  by  several 


Pig.    151. — Hepatico-enterostomy  by  Means  of  a  Rubber  Tube. 

fine  catgut  sutures.  After  the  retaining  sutures  of  catgut  have  been 
absorbed  the  tube  is  drawn  into  the  intestine  by  the  tug  on  the  sponge 
tip  exerted  by  intestinal  peristalsis.  A  more  or  less  permanent  channel 
is  formed  in  this  way,  permitting  the  discharge  of  bile  into  the  intes- 
tine. Most  surgeons  who  have  adopted  this  method  have  not  employed 
any  sponge  attached  to  the  end  of  the  tube  which  enters  the  duo- 
denum, (Fig.  151)  and  personally  we  are  of  the  opinion  that  it  is 
unnecessary. 


5l8  SURGERY    OF    THE    GALL-BLADDER   AND   BILE -DUCTS 

Case  histories  reported  by  various  authors,  abstracts  of  which 
were  pubhshed  in  the  first  edition  of  this  work,  show  that  up  to  that 
time  (1913)  the  choledochus  had  been  restored  by  means  of  a  rubber 
tube  in  no  less  than  12  cases;  all  the  patients  survived,  but  in  only  8 
does  permanent  relief  appear  to  have  been  secured.  In  several  in- 
stances the  tube  never  was  recovered  from  the  feces,  but  as  it  could 
not  be  detected  by  the  X-rays  it  was  presumed  to  ha^-e  passed  un- 
noticed. Brandt  (191 2)  thinks  it  desirable  that  it  should  remain 
permanently  in  situ. 

The  following  patients  in  whom  hepatico-enterostomy  was  re- 
quired have  come  under  the  care  of  the  senior  author: 

BiLLARY  Calculus,  Common  Duct  Obstruction,  Retrovtlrted  Uterus.  Chole- 
cystectomy; Choledochostomy;  Suspension  of  Uterus.  Recovery. 
Complete  Occlusion  of  Common  Duct.  Hepatico-duodenostomy  by  Rub- 
ber Tube.     Recovery 

C.  T.,  aged  54  years,  admitted  to  German  Hospital,  January  jo,  1914. 

Co7nplaint. — Pain  in  right  epigastrum  and  right  costal  margin. 

Family  history. — Negative  except  for  carcinoma  (an  aunt.) 

Social  history. — Negati\x. 

Past  medical  history. — Displacement  of  uterus  several  years  ago.  Menorrhagia. 
Double  nephropexy  for  floating  kidney.     Appendicitis  five  years  ago. 

Present  illness. — Eight  months  ago  patient  began  to  have  violent  cramp-like 
pains  in  the  epigastrium  and  along  the  right  costal  margin,  radiating  to  the  left 
shoulder.  Pains  have  at  times  caused  vomiting  of  sour  greenish  material.  Pain 
is  not  related  to  eating.  Has  had  indigestion  and  belching  of  gas  for  a  number  of 
years.  Bowels  have  been  constipated  since  onset  of  present  illness.  .\t  present 
the  attacks  of  pain  recur  every  four  or  five  days  and  are  always  accompanied  by, 
nausea,  vomiting,  chUls,  and  fever.  Patient  has  been  jaundiced  since  May  last, 
the  jaundice  increasing  in  severity  with  each  attack. 

Physical  examination. — Abdomen,  soft,  flat;  old  operative  wound  in  lower  right 
quadrant.    Very  tender  to  the  touch  in  the  gall-bladder  region. 

Operation. — January  21,  1914.  Dr.  Deaver.  Ether  anesthesia.  Upper  right 
rectus  incision.  Foramen  of  Winslow  patulous.  Head  of  pancreas  slightl\' 
enlarged.  Gall-bladder  small;  opened  and  stones  removed.  Cystic  duct  and 
artery  damped,  gall-bladder  removed.  Probe  passed  through  stump  of  cystic 
duct  into  duodenum.  Gall-bladder  bed  oversewn  with  iodized  gut.  Cystic  duct 
and  artery  tied.  One  rubber  tube  with  selvage  gauze  passed  into  subhepatic 
fossa.  Wound  closed  in  layers  to  drainage.  Lower  right  rectus  incision,  etc., 
suspension  of  uterus. 

Postoperative  course. — Patient  began  10  drain  bile  through  tube  on  second 
day  after  operation;  drainage  continued  in  large  quantities  after  tube  was  removed. 
Stools  clay-colored.  Patient  weak  and  uncomfortable.  Skin  still  somewhat 
jaundiced. 

February  25. — For  past  three  days  patient  has  been  running  a  septic  tempera- 


HEPATICO-DUODENOSTOMY  SI9 

ture.  "Complains  of  pain  in  incision.  Purulent  discharge  from  sinus.  Drainage 
still  abundant. 

Operation. — February  25,  Dr.  Deaver.  Ether  anesthesia.  Incision  through 
old  scar.  Viscera  packed  off  with  gauze.  Strong  adhesions  to  gall-bladder  fossa 
over  gastro-hepatic  omentum.  Search  for  common  duct  unsuccessful.  Adhesions 
of  omentum  to  duodenum  tied  and  cut.  Duodenum  opened  and  papilla  of  Vater 
identified.  Common  duct  had  been  destroyed,  and  a  probe  passed  free  into  peri- 
toneal cavity.  One  end  of  a  "T"-tube  was  passed  into  the  hepatic  duct  and 
sutured;  the  other  end  was  passed  into  the  remains  of  the  common  duct  and  sutured 
with  plain  catgut  suture.  Duodenum  closed  with  muco-muscular  and  musculo- 
serous  sutures  of  chromic  gut,  reinforced  with  sero-muscular  suture  of  linen.  Bile 
found  to  be  leaking  from  proximal  end  of  duct.  Probe  passed  into  liver.  Great 
omentum  brought  over  line  of  suture  in  duodenum  to  reinforce  duodenum.  Duo- 
denum friable  and  idcerated  from  breaking  up  of  adhesions.  Rubber  tube  and 
cigarette  drain  passed  into  subhepatic  fossa.  Hemostasis  with  No.  2  iodized  gut. 
Wound  closed  in  layers;  skin  with  silkworm  gut.  Dry  dressing.  March  24,  1915. 
Patient  dismissed,  with  "T"-tube  in  silu,  but  cut  off  flush  with  the  abdominal  wall. 
Wound  had  healed  except  around  the  tube. 

Blood  count  (1-20-15). — Hemoglobin,  64  per  cent.  R.  B.  C,  4,210,00.  \V.  B.  C, 
5,700;  coagulation  time  5  minutes. 

(2-24-15)  Hem.,  74  per  cent.  R.  B.  C,  4,  290,000.  W.  B.  C.  11,900;  coagula- 
tion time  8  minutes. 

Culture  of  bile. — B.  coli  com. 

Culture  of  duodenum  sterile. 

The  patient  returned  to  the  hospital  November  11,  1915,  still  wearing  the 
"T"-tube.  For  about  six  weeks  after  operation  the  jaundice  had  cleared  but  soon 
reappeared.  At  present  she  has  periodic  attacks  of  chills  and  fever,  with  deepening 
jaundice,  sometimes  clearing  partially  and  again  growing  deeper.  Patient  com- 
plains of  severe  diarrhea  and  intense  itching  which,  to  use  her  expression,  sets 
her  crazy;  distension,  flatulence,  belching,  and  frequent  vomiting.  Describes 
feeling  in  right  hypochondrium  as  though  "something  were  giving  away."  Appe- 
tite fair,  bowels  constipated,  stools  light,  urine  dark.  Has  not  been  able  to  work 
since  operation. 

Physical  examination. — No  masses  palpable,  but  there  is  a  feeling  of  resistance 
and  rigidity  in  the  upper  right  quadrant.  Peristalsis  normal.  Liver  and  kidney 
not  palpable.    Jaundice  deep. 

Blood  pressure,  130-78. 

Blood  count. — (11-19-15).  Hem.  60  per  cent.  R.  B.  C.  3,730,000;  W.  B.  C. 
7,100;  coagulation  time  7  minutes. 

Operation. — November  22,  1915.  Dr.  Deaver.  Ether  anesthesia.  Curved 
incision  around  old  scar.  Old  scar  removed.  Old  "  T  "-tube  left  in  tract  to  serve 
as  a  guide.  Peritoneum  opened.  Peritoneum  adherent  to  stomach,  and  duodenum 
adherent  to  liver.  The  great  omentum  had  to  be  delivered  to  get  the  relations. 
The  old  "T"-tube  communicated  with  the  liver  but  not  with  the  common  duct. 
The  hepatic  duct  was  located  with  much  difficulty;  opened  and  great  quantities 
of  fluid,  such  as  comes  from  a  hydrops  of  the  gall-bladder,  exuded.  A  rubber  tube, 
about  the  calibre  of  the  little  finger,  was  sewn  into  the  hepatic  duct,  and  the  other 
end  of  the  tube  was  sewn  into  the  opening  in  the  duodenum  which  the  old  "T"-tube 


520  SURGERY    OF    THE    GALL-BLADDER    AND    BILE -DUCTS 

had  made,  an  anastomosis  between  the  hepatic  duct  and  the  duodenum  being  thus 
formed.  One  rubber  tube  was  put  into  the  renal  well;  another  down  to  site  of 
anastomosis.  Wound  closed  in  layers  to  drainage  with  No.  2  iodized  gut;  skin  with 
silkworm  gut.     Drj-  dressing. 

Patient "s  jaundice  cleared  entirely  immediately  after  operation.  Recovery 
was  uneventful. 

The  patient  was  seen  again  six  months  after  her  dismissal  from  the  hospital. 
She  was  gaining  in  weight  and  was  in  excellent  health. 


Chronic  Cholecystitis;  Internal  Biliary  Fistula.  Repair  of  Duodenum^ 
Cholecystectomy.  Gastro-jejunostomy.  Recovery.  Recurrence  of 
Obstructhe  Jaundice;  not  Relie\t;d  by  Hep.\tico-duodenostomy 

I.  W.,  female,  aged  fifty-five  years,  admitted  to  German  Hospital,  June  7,  1914. 

Past  medical  history. — Jaundice  10  years  ago  but  does  not  remember  any  attacks 
of  pain.     Pneumonia  10  j-ears  ago.     Typhoid  fever  5  years  ago. 

During  the  past  ten  years  she  has  had  pain,  not  sharp,  in  the  right  upper  abdo- 
men, w-ith  a  constant  dull  hea\'>'  feeling.  Xo  chills,  fever,  or  jaundice.  Be- 
comes nauseated  after  eating  but  does  not  vomit.  Is  constantly  distended  with 
gas.  and  belches  considerably,  .\ppetite  poor.  Bowels  very  constipated.  No  loss 
of  weight.     Drj'  cough  since  March,  1914. 

Physical  examination. — Tenderness  and  moderate  rigidity  over  ninth  right  costal 
margin,  and  some  tenderness  in  epigastrium. 

Operation,  by  Dr.  Deaver,  June  7,  1914.  Ether  anesthesia.  Upper  right  rectus 
incision.  Gall-bladder  adherent  to  duodenum  and  a  direct  fistula  was  present. 
The  gall-bladder  was  separated  and  the  opening  in  the  duodenum  invaginated  with 
linen.  A  thickened  and  contracted  gall-bladder  removed.  Bed  over-sewn  with 
number  2  iodin  gut.  Adhesions  at  duodeno-jejunal  junction  freed.  The  duodenum 
having  become  contracted  by  invagination  of  the  fistula,  a  posterior  gaslro-jejunos- 
tomy  was  done.  One  glass  tube  in  subhepatic  fossa.  Wound  closed  in  layers.. 
Dry  dressing.  Patient  left  the  hospital,  July  7,  1914,  against  advice.  The  wound 
was  granulating  at  the  time. 

She  was  re-admitted  to  the  German  Hospital,  September  9,  1914.  Two  weeks 
after  leaving  the  hospital  she  had  an  attack  of  severe  cramp-like  pain  all  over  the 
abdomen,  accompanied  by  fever,  chills,  vomiting,  jaundice.  She  has  not  felt  well 
since  that  time  and  has  had  several  subsequent  attacks  of  chills,  fever,  and  jaun- 
dice, with  pain  in  the  right  hypochondrium  radiating  to  the  back.  Eating  is  reg- 
ularly followed  by  pain  in  the  epigastrium  and  by  nausea  and  occasional  vomiting, 
which  sometimes  relieves  the  condition.  Belches  considerable  gas.  Jaundice  is 
now  constant;  stools  are  clay  colored,  urine  dark;  and  skin  itches.     Has  lost  weight. 

Physical  examinatian. — Shows  the  scar  of  the  previous  operation  also  tenderness 
and  rigidity  in  the  epigastrium  and  the  right  hypochondrium. 

Operation. — September  15,  1915.  Dr.  Deaver.  Ether  Anesthesia.  Incision 
around  old  scar.  Adhesions  of  omentum  to  liver  and  intestines  cut  and  tied. 
Cystic  degeneration  of  omentum.  Gastro-jejunostomy  opening  in  good  condition. 
Pancreas  normal.  No  stones  found  in  common  duct.  Common  duct  aspirated 
and  incised,  a  cloudy  waterj'  fluid  escaping.     Culture  taken.     Hepatic  duct  probed 


BILIARY    OBSTRUCTION   FROM   CAUSES    OUTSIDE    OF    THE   DUCTS    52 1 

and  patulous.  Xo  opening  found  in  distal  end  of  common  duct.  Duodenum 
incised  and  "T"-tube  placed  from  hepatic  duct  to  duodenum.  One  cigarrette 
drain  placed  below  omentum,  and  omentum  brought  down  over  duodenum.  One 
piece  of  rubber-dam  to  subhepatic  fossa.  Wound  closed  to  drainage.  Skin  with 
silkworm  gut.     Dry  dressing.     Patient  transfused,  iSoo  cc.  saline,  on  table. 

External  biliary  fistula  had  not  completely  closed  when  the  patient  was  dis- 
charged, October  22. 

The  patient  returned  to  the  hospital  during  the  winter,  complaining  of  the  same 
symptoms  as  before  and  wanting  to  undergo  another  operation,  which  Dr.  Deaver 
did  not  deem  advisable.  Death  occurred  about  six  months  after  the  hepatico- 
duodenostomy,  jaundice  having  persisted  until  the  end. 

Biliary  Obstruction  from  Causes  Outside  of  the  Ducts. — The  most 
frequent  of  these  causes  is  the  presence  of  pericholecystic  adhesions 
(page  452),  which  cause  kinking  of  the  cystic  or  common  duct.  The 
symptoms  and  treatment  of  this  condition  have  been  considered  at 
pages  452  and  483. 

Obstruction  from  diseases  of  the  pancreas  is  discussed  at  page  694. 

Obstruction  from  carcinoma  of  the  papilla  of  Vater  is  not  very  rare 
(page  588). 

Obstruction  from  kinking  of  the  ducts  due  to  the  presence  of  a  movable 
kidney  was  first  recognized  by  Wiessker,  in  1888,  and  was  studied  by 
Tinker  (1907).  According  to  Tinker,  Apolant  believes  that  many  of 
the  patients  treated  at  Carlsbad  for  supposed  affections  of  the  biliary 
tract  are  in  reahty  suffering  from  pressure  of  a  misplaced  kidney. 
Tinker  reports  two  cases  of  his  own  in  which  the  patients  secured  im- 
mediate and  permanent  relief  of  all  symptoms  referable  to  the  biliary 
tract  after  the  operation  of  nephropexy.  The  symptoms  presented  are 
those  of  interference  with  the  normal  flow  of  bile,  indigestion,  nausea 
and  occasionally  vomiting,  pain  in  the  right  hypochondrium  referred 
to  the  back  or  shoulder,  and  in  some  cases  intermittent  jaundice. 
Although  the  symptoms  all  point  to  the  biliary  tract,  they  are  relieved 
by  the  return  of  the  kidney  to  its  normal  position,  either  by  manipula- 
tion, or  when  the  patient  assumes  the  recumbent  position. 

The  diagnosis  usually  is  not  made  until  operation  has  demon- 
strated that  there  are  no  lesions  in  the  biliary  tract.  The  possibility 
of  a  movable  kidney  as  a  cause  should  be  borne  in  mind,  and  in  cases  of 
doubt  this  factor  should  be  eliminated  by  rest  in  bed  or  the  use  of  a 
well-fftting  corset  with  a  kidney  pad,  before  operation  is  undertaken. 
When  it  has  been  ascertained  definitely  that  a  movable  kidney  is  the 
cause  of  the  biliary  symptoms,  the  operation  of  nephropexy  should  be 
advised. 

Obstruction  from  fibro-adenoma  forming  in  the  stump  of  the  cystic 


52  2  SURGERY    OF    THE    GALL-BLADDER   AND   BILE-DUCTS 

duct  after  cholecystectomy  was  encountered  by  Mayo  (1915)  in  two 
cases. 

Obstruction  from  Aneurysm. — This  is  a  rare  cause  of  biliary  obstruc- 
tion. According  to  Villandre  (1909),  most  cases  have  developed 
shortly  after  some  acute  infection,  especially  pneumonia  or  typhoid 
fever.  The  aneurism  may  effect  the  abdominal  aorta,  or  the  heptaic 
artery  or  one  of  its  branches.  Fleckenstein  (19 13)  says  Bosdorf 
(1889)  found  one  aneurysm  of  the  hepatic  artery  among  93  aneurysms 
encountered  at  autopsy  on  3108  adults;  and  that  Miller  (1902)  found 
3  among  171  aneurysms  in  6425  autopsies  on  adults.  Verrey  (191 1) 
collected  42  cases  of  aneurysm  of  the  hepatic  artery,  and  Fleckenstein's 
case  made  the  forty-third  on  record,  but  there  is  a  reference  at  least  to 
one  case  in  nearly  every  recent  volume  of  the  Index  Medicus.  The 
symptoms  to  attract  attention  usually  have  been  those  of  pressure,  and 
not  any  symptoms  attributable  to  the  aneurj'sm  as  such.  In  most 
cases  the  diagnosis  has  been  made  only  at  autopsy.  Villandre  thinks 
that  if  the  triad  of  symptoms  (local  pain,  intestinal  hemorrhages,  and 
jaundice)  is  present,  the  existence  of  an  aneurysm  of  the  hepatic  artery 
should  be  suspected.  These  are  the  most  characteristic  symptoms, 
but  one  or  more  often  is  absent.  Intestinal  hemorrhage  alone  may  be 
attributed  to  duodenal  ulcer,  and  even  when  associated  with  local  pain 
and  jaundice  might  be  due  to  malignant  obstruction  of  the  common 
duct. 

Villandre  collected  the  following  cases  of  aneurysm  of  the  hepatic 
artery  in  which  operation  was  done: 

Mikulicz:  lesion  not  found;  gastro-enterostomy.  Death  in  six  days.  Diagnosis 
at  autopsy. 

Riedel:  incised  aneurysm,  thinking  it  was  calculus  in  common  duct;  tampon 
for  hemorrhage.  Second  operation,  twenty  days  later,  abandoned  and  tamponed 
for  hemorrhage.     Death  in  three  days.     Diagnosis  at  autopsy. 

Heller:  found  blood  in  abdominal  cavity,  mesocolon,  and  in  gall-bladder  and 
cystic  duct.     Tamponed.     Death. 

Habs  (report  by  Grunert):  after  cholecystectomy  recognized  aneur>-sm  of 
hepatic  artery  as  cause  of  choledochus  obstruction.  Nothing  further  done.  Death 
in  eight  days. 

.•\llessandri :  cholecystotomy;    hemorrhage;    tampon.     Death    in    five    days. 

Tuffier:  incised  mass  in  gastro-hepatic  omentum;  profuse  hemorrhage;  ligated 
hepatic  arterj-.     Death  in  four  days. 

Kehr:  incised  gall-bladder;  gush  of  blood,  controlled  only  by  ligation  of  hepatic 
arterj-.  The  gall-bladder  was  then  extirpated  and  sac  of  aneur>'sm  packed.  Aneur- 
ysm had  ruptured  into  gall-bladder  and  further  hemorrhage  prevented  only  by 
plugging  of  cystic  duct  by  clot.  Recovered,  and  according  to  Bode  in  good  health 
sue  years  later  (Fig.  152). 


ANEURYSM  OF  HEPATIC  ARTERY  523 

To  these  may  be  added  an  operation  by  Garre,  reported  by  Bode:  (1909)  over 
a  year  after  an  injury  to  the  right  thorax  Garre  operated  on  a  patient  who  presented 
symptoms  of  pyloric  obstruction  with  gastro-intestinal  hemorrhages.  The  diag- 
nosis was  gastric  ulcer,  and  gastro-enterostomy  was  done.  The  patient  died  a  week 
later,  and  at  autopsy  an  aneurysm  was  found  on  an  intrahepatic  branch  of  the  hepa- 
tic artery;  this  had  ruptured  into  one  of  the  intrahepatic  bile-ducts,  but  there 
had  been  no  recent  hemorrhages.  There  were  scars  of  old  injury  in  the  liver  and 
right  kidney. 


Fig.  152. — Kehr's  Case  of  Aneurysm  of  the  Hepatic  Artery  which  had  Ruptured  into  the 
Gall-bladder.     Ligature  on  the  Hepatic  Artery. 

Baruch  (1914)  also  reported  a  case,  in  which,  at  operation  undertaken  for  symptoms 
of  obstructive  jaundice  without  palpable  enlargement  of  the  gall-bladder,  a  compressible 
tumor,  the  size  of  a  goose-egg,  was  found  and  was  mistaken  for  the  choledochus;  puncture, 
however,  drew  pure  blood.  After  cholecyslectomy  it  was  impossible  to  insert  a  probe  into 
the  cystic  duct,  so  after  mobilization  of  the  duodenum  the  hepatic  duct  was  exposed.  It 
was  drained  above  the  point  of  obstruction  by  the  aneurysm,  but  the  patient  died  the  next 
day.  Autopsy  showed  the  aneurysm  involved  the  hepatic  artery  on  the  liver  side  of  the 
origin  of  the  gastro-duodenal  artery. 

Rational  operation  (ligation  of  the  hepatic  artery)  was  done  only  in 
two  cases,  those  of  Tuffier  and  Kehr. 

Kehr's  is  the  only  patient  who  recovered.  Villandre  conducted 
experiments  on  dogs,  to  ascertain  the  feasibility  of  survival  after  liga- 
tion of  the  hepatic  artery.  Though  few  in  number  these  experiments 
tended  to  demonstrate  that  while  gradual  occlusion  is  safe,  yet  rapid 
occlusion,  such  as  occurs  in  embolus  or  after  ligation  of  the  normal 


524  SURGERY    OF    THE    CALL-BLADDER    AND    BILE-DUCTS 

artery,  always  is  fatal.  Evidently  in  Kehr's  case  adequate  collateral 
circulation  had  been  established  before  the  operation,  only  a  segment 
of  the  liver  along  its  anterior  border  becoming  necrotic.  It  is  note- 
worthy that  Kehr  has  also  successfully  ligated  the  hepatic  artery  in  one 
case  for  hemorrhage  during  choledochotomy. 

Korte  did  cholecystenterostomy  for  obstruction  from  a  mass  at  the 
papilla  of  Vater  (probably  a  congenital  stricture) ;  death  occurred  from 
internal  hemorrhage,  and  at  autopsy  a  thrombosed  aneurysm  was  found 
in  the  course  of  the  bile-ducts.     This  had  not  caused  any  symptoms. 

Portal  thrombosis,  according  to  Bode  (1909),  has  been  treated  by 
operative  means  in  eight  cases,  only  three  patients  recovering — two 
after  the  Talma  operation  for  ascites  from  cirrhosis  of  the  liver  (epiplo- 
pexy),  and  one  after  simple  drainage  of  the  ascitic  fluid. 

Biliary  Fistula 

A  biliary  fistula  is  one  that  discharges,  or  has  discharged  bile. 
Such  listulae  are  not  uncommon.  They  result  in  most  cases  at  the 
present  day  from  operations  on  the  biliary  tract;  but  they  may  also 
be  caused  by  inflammatory  changes  with  perforation,  or  from  carcinoma 
of  the  gall-bladder  or  bile-ducts.  They  are  classified  as  internal  or 
external.  External  fistula;  are  those  which  open  upon  the  surface  of 
the  body;  internal  fistula  are  those  which  communicate  with  one  of 
the  internal  organs. 

Courvoisier  (1890)  collected  the  following  statistics  in  regard  to  the 
location  of  biliary  fistulae  in  499  cases. 

Courvoisier's  Statistics  of  Biliary  Fistula 

External  fistulae 196    cases 

Internal  fistuls 303    cases 

Between  biliary  tract  and  peritoneal  cavity 7° 

Between  biliary  tract  and  peritoneal  adhesions 4q 

Between  biliary  tract  and  retroperitoneal  tissues 3 

Between  biliary  tract  and  portal  vein 5 


127 


Between  biliary  tract  and  thoracic  organs 24       24 

Between  biliary  tract  and  urinary  organs 7         7 

Between  biliary  tract  and  other  abdominal  viscera: 

Stomach 13 

Duodenum 83 

Jejunum. i     137 

Ileum I 

Colon 39 

Between  biliary  tract  and  other  portions  of  biliary  tract 8 


Total  internal  fisluhe 303 


INTERNAL   BILIARY   FISTULA  525 

Internal  Biliary  Fistula. — A  fistulous  opening  between  the  biliary 
tract  and  one  of-  the  adjacent  viscera  may  occur  after  an  adhesive 
peritonitis  has  bound  the  two  structures  together;  this  forms  the  direct 
variety  of  internal  fistula.  If  the  communication  occurs  through  an 
abscess  cavity,  the  affected  viscera  not  being  in  direct  contact,  the 
fistula  is  said  to  be  of  the  indirect  variety.  As  a  rule,  perforations  of 
the  biliary  tract  into  the  free  peritoneal  cavity  or  into  peritoneal  adhe- 
sions are  not  classed  as  biliary  fistulas,  though  they  are  included  in 
Courvoisier's  statistics  quoted  above. 

A  true  fistula  may  exist  between  two  or  more  of  the  biliary  passages 
themselves;  between  the  biliary  passages  and  the  substance  of  the 
liver  or  pancreas;  or  the  fistula  may  join  the  gall-bladder  or  ducts  with 
the  lumen  of  the  stomach,  duodenum,  colon,  or  some  portion  of  the 
small  intestine.  Robson  (1909)  observed  during  a  period  of  six  years 
no  fewer  than  five  cases  of  internal  biUary  fistula:  3,  between  gall- 
bladder and  duodenum,  and  2  between  gall-bladder  and  stomach.  In 
one  of  the  latter  cases  the  gall-bladder  had  prolapsed  into  the  stomach 
through  the  fistula.  There  are  on  record  a  number  of  cases  of  biliary 
fistulse  communicating  with  the  urinary,  thoracic  (pulmonary,  pleural, 
pericardial,  mediastinal),  and  female  pelvic  organs,  but  these  are  patho- 
logical curiosities  and  have  comparatively  little  interest  for  the  surgeon. 
Usually  they  have  been  found  at  autopsy,  or  have  developed  so  soon 
before  death  that  no  attempt  at  operative  rehef  has  been  justifiable. 
They  are  much  rarer  now  than  in  the  period  before  diseases  of  the  biliary 
tract  came  under  the  domain  of  surgery. 

Symptoms. —  When  the  biHary  fistula  is  of  such  size  as  to  permit  the 
discharge  from  the  gall-bladder  of  all  its  contained  calculi,  with  free 
drainage  of  the  infected  biliary  tract,  all  inflammatory  symptoms 
quickly  subside.  Nature's  cholecystenterostomy  often  is  as  successful 
as  an  operative  anastomosis  in  relieving  the  patient  of  distressing 
symptoms.  The  true  condition  of  affairs  may  be  surmised,  if  a  patient 
passes  by  rectum  one  or  more  calculi  too  large  to  have  traversed  the 
bile-ducts;  in  one  case  on  record  the  diagnosis  was  made  from  the  fact 
that  the  patient  vomited  gall-stones.  In  this  case  recovery  ensued 
without  operation. 

The  following  cases  represent  progressive  stages  in  the  development 
of  internal  bihary  fistulae: 

Pericholecystitis;  Calculi  among  Adhesions  around  Gall-bladder,  Chole- 

CYSTOSTOMY.     Recovery 

R.  Z.,  female,  aged  thirty  years;  admitted  to  the  German  Hospital  November  22, 
1906.     Mother  died  of  carcinoma  of  the  liver.     Patient  had  typhoid  fever  when 


526  SURGERY    OF   THE    GALL-BLADDER    AND   BILE-DUCTS 

twenty  years  old.  Bowels  always  constipated.  For  fifteen  years  has  had  attacks 
of  pain  in  epigastric  and  gall-bladder  regions,  with  vomiting.  No  jaundice  until 
four  months  ago,  when  she  had  jaundice  with  chills  and  fever. 

Examination. — No  jaundice  on  admission.  Liver  normal ;  gall-bladder  palpable. 
Tenderness  and  rigidity  in  gall-bladder  area.     W.  B.  C,  10,000. 

Operation  by  Dr.  Deaver.  Ether  anesthesia.  Incision  splitting  fibres  of  upper 
right  rectus.  Adhesions  around  gall-bladder,  and  between  it  and  the  omentum. 
On  the  outside  of  the  wall  of  the  gall-bladder  were  several  gall-stones  which  seemed 
to  have  worked  their  way  gradually  through  the  walls  of  this  viscus.  They  seemed 
to  be  very  lightly  attached  to  the  gall-bladder  and  fell  off  during  light  manipulation. 
The  gall-bladder  was  distended  and  packed  with  stones.  Stones  removed  and 
gaU-bladder  drained  with  rubber  tube.  Recovery.  (Note:  Plate  VI  shows  a 
similar  condition  in  a  patient  treated  by  cholecystectomy.) 

Cholelithiasis;  Cholecysto-gastric   Fistula.     Cholecystectomy;  Repair  of 
Stomach;  Drainage  of  Choledochus.    Recovery 

Mrs.  W.  D.,  aged  42  years;  admitted  to  the  German  Hospital  April  10,  1911. 
Has  had  numerous  attacks  of  biliarj-  colic,  extending  over  many  years.  Has  made 
several  trips  to  Carlsbad,  always  with  temporary  improvement.  Operation  under- 
taken because  of  persistent  recurrence  of  attacks. 

Operation  by  Dr.  Deaver.  Ether  anethesia,  preceded  by  nitrous  oxide.  Inci- 
sion splitting  fibres  of  upper  right  rectus,  extended  inward  along  costal  margin. 
Duodenum  and  pylorus  bound  by  strong  adhesions  to  fundus  of  gall-bladder  and 
lower  surface  of  liver.  On  releasing  adhesions  a  perforation  of  stomach  and  of  gall- 
bladder was  found,  with  a  large  gall-stone  protruding  into  stomach.  Adhesions 
freed  and  opening  in  stomach  closed.  The  free  border  of  gastro-hepatic  omentum 
was  next  opened,  exposing  cystic  and  common  ducts.  Cystic  duct  and  arterj' 
ligated  and  cut,  and  gall-bladder  removed,  after  calculus  had  been  pushed  back  into 
gall-bladder.  Gall-bladder  was  thickened  and  contracted.  A  large  stone,  the  size 
of  end  of  thumb,  occupied  gall-bladder  cavity.  Mucosa  of  gall-bladder  edematous 
and  ulcerated.  Margin  of  cystic  duct  grasped  with  heniostat  and  probe  passed , 
down  common  duct  to  duodenum;  hepatic  ducts  also  free  from  obstruction.  Small 
rubber  tube  sutured  into  cystic  duct  opening  with  chromic  catgut.  Gastro-hepatic 
omentum  then  closed  around  tube.  Split  tube  and  piece  of  gauze  then  sutured  into 
gall-bladder  fossa  on  under  surface  of  liver,  sutures  passing  through  liver  sub- 
stance.   Small  glass  tube  to  sub-hepatic  fossa.    Uneventful  recovery. 

Most  of  the  internal  fistulas  tend  to  close  spontaneously,  but  the 
resulting  adhesions  often  cause  very  distressing  symptoms.  These 
adhesions  may  cause  pyloric  obstruction,  kinking  of  the  common 
duct,  interference  with  intestinal  peristalsis,  or  even  acute  intestinal 
obstruction.  If  the  internal  biliary  fistula  remains  patulous,  and  if  the 
cystic  duct  is  patulous,  obstruction  of  the  common  duct  may  not 
produce  any  noteworthy  symptoms,  as  the  bile  will  be  able  to  drain 
into  the  intestinal  tract  through  the  fistula.  When  the  bile  is  dis- 
charged into  the  colon  there  are  more  digestive  symptoms  than  whenit 


EXTERNAL    BILIARY    FISTULA  527 

escapes  into  the  duodenum  or  stomach.  Interference  with  the  function 
of  the  pancreas  may  occur,  and  may  eventually  demand  operative 
relief.  In  a  case  reported  by  Leonardi  (1909)  the  entire  gall-bladder 
was  discharged  as  a  slough  into  the  intestine  through  an  internal 
biliary  fistula,  and  was  passed  by  rectum. 

Treatment. — As  the  true  lesion  scarcely  ever  is  recognized  until 
after  the  abdomen  has  been  opened,  the  surgeon  must  be  prepared 
to  meet  the  conditions  as  they  exist.  It  is  seldom  possible  and  very 
rarely  is  it  proper  to  return  the  various  viscera  involved  in  the  adhesions 
to  their  normal  relations.  In  most  cases  the  intestinal  or  gastric 
opening  can  be  closed  by  careful  suture;  if  this  narrows  the  lumen  to  a 
dangerous  degree  a  short  circuiting  operation  should  supplement  the 
repair  of  the  fistulous  opening.  Only  in  rare  cases  is  an  intestinal 
resection  required.  The  biliary  side  of  the  fistula  is  most  easily  relieved 
by  cholecystectomy,  when  the  fistula  communicates  with  the  gall- 
bladder or  cystic  duct;  in  such  cases  as  well  as  in  those  where  the  com- 
mon or  hepatic  duct  are  involved  in  the  fistula,  drainage  of  the  main 
bile-channels  (choledochus  or  hepaticus)  should  be  instituted. 

External  Biliary  Fistulae. — Most  of  the  external  biliary  fistulas 
encountered  at  the  present  day  are  the  result  of  an  operation,  and 
develop  in  the  operative  cicatrix.  Those  which  form  spontaneously, 
and  which  sometimes  are  called  "pathological,"  may  open  almost  at 
any  point  of  the  abdominal  wall.  The  situation  of  the  skin  opening 
depends  upon  the  size  and  position  of  the  gall-bladder,  and  upon 
whether  or  not  the  fistula  communicates  directly  with  the  gall-bladder 
or  ducts,  or  passes  through  an  intervening  abscess  cavity  by  a  long 
and  tortuous  channel.  In  the  series  of  cases  collected  by  Courvoisier 
(1890)  the  fistulous  openings  were  in  the  following  situations: 

In  the  right  hypochondrium 4g 

At  right  costal  border 36 

On  right  side  of  epigastrium. .                            17 

In  epigastrium 6 

In  right  iUac  fossa 10 

Near  umbilicus 22 

At  umbilicus 11 

In  left  groin ' i 

Multiple  openings i 

External  biHary  fistulae  are  classed  as  complete  (biliary)  or  incomplete 
(mucous),  according  to  whether  or  not  they  discharge  bile.  Practi- 
cally all  the  spontaneous  or  so-called  pathological  fistulas  are  complete. 


528  SURGERY    OF    THE    GALL-BLADDER    AND   BILE-DUCTS 

The  diagnosis  is  made  by  the  recognition  of  bile  in  the  discharge.  In 
most  cases  calcuh  also  escape  from  time  to  time.  In  a  case  reported 
by  Gutteridge  (1878)  a  single  stone  3  inches  in  diameter  was  discharged 
in  this  way.  Usually  such  a  fistula  persists  until  all  calculi  present  in 
the  biliary  passages  have  been  discharged;  it  may  then  close  of  itself. 
But  the  period  of  time  during  which  it  will  remain  open  cannot  be  fore- 
told, and  in  most  cases  early  operation  is  indicated  to  remove  the  re- 
maining calculi,  and  restore  the  intestinal  drainage  of  bile. 

.\bscess  of  Abdominal  Wall  from    Perforation  of  Gall-bladder;  Calculi 
IN  Gall-bladder.     Cholecystostomy.     Recovery 

M.  R.,  female,  aged  forty-one  years;  admitted  to  German  Hospital,  October  20, 
1904.  Two  brothers  had  had  gall-stones.  Patient  never  had  had  typhoid  fever. 
Present  illness  began  twenty-three  years  ago,  with  severe  pains  in  epigastrium  and 
vomiting;  indigestion  after  eating,  accompanied  by  much  flatidence.  Last  attack 
of  severe  pain  five  years  before  present  one,  which  has  been  more  or  less  constant 
during  last  five  months  with  dull  pain  in  gall-bladder  region  referred  to  back; 
lately  pains  have  been  sharp  and  shooting. 

Examination. — Edema  of  abdominal  wall  in  gall-bladder  region,  with  swelling, 
redness  and  tenderness.  Marked  tenderness  in  right  hypochondrium.  Hemo- 
globin, 61  per  cent.,  W.  B.  C,  9200. 

Operation,  by  Dr.  Deaver.  Ether  anesthesia.  Incision  over  mass  in  abdominal 
wall  which  proved  to  be  an  abscess  communicating  with  fistulous  opening  in  the 
gall-bladder.  Adhesions  between  gall-bladder,  stomach,  duodenum,  and  colon. 
Adhesions  not  disturbed.  Liver  enlarged  and  congested.  Three  small  and  one 
large  calculi  removed  from  gall-bladder  through  fistula.  Drainage  of  gall-bladder. 
Recovery. 

Postoperative  fistulae  may  be  either  mucous  or  biliary. 

A  postoperative  mucous  fistula  is  very  rare  if  the  gall-bladder  has 
been  removed;  usually  it  indicates  that  the  cystic  duct  is  no  longer 
patent,  and  that  the  gall-bladder  is  a  iiseless  appendage.  The  cystic 
duct  usually  is  closed  by  cicatricial  changes  which  are  the  result  of 
previous  disease,  but  in  some  instances  closure  is  due  to  impaction 
of  a  calculus.  There  is  a  more  or  less  constant  flow  of  muco-purulent 
material  from  the  fistula,  but  the  discomfort  produced  may  be  very 
slight,  the  amount  of  the  discharge  seldom  being  more  than  30  to  40 
c.c.  (i  ounce)  in  twenty-four  hours.  Should  the  external  opening 
close,  however,  the  discharge  will  accumulate  within  the  fistulous 
tract,  causing  severe  pain  and  at  times  symptoms  of  septic  absorption. 
Should  operation  be  inadvisable  for  any  reason,  or  should  it  be  refused, 
the  external  opening  of  the  fistula  should  be  kept  patulous  by  the  use  of 
a  tube.  The  following  case  illustrates  this  condition,  as  well  as  the 
method  or  cure  by  operation. 


POST-OPEFAXrVE    BILIARY    FISTULA  529 

Mary  S.,  aged  twenty-seven  years,  was  operated  upon  in  the  German  Hospital 
in  190S,  for  gall-stones,  a  cholecystostomy  being  performed.  The  sinus  was  almost 
closed  when  she  went  home.  Shortly  after  it  closed  she  had  severe  crampy  pains 
in  the  region  of  operation.  The  fistula  was  opened,  with  immediate  relief,  and  a 
rubber  drainage  tube  was  inserted  into  the  tract.  This  was  worn  by  the  patient 
for  over  two  years.  The  discharge  consisted  of  white  muco-purulent  material. 
Two  weeks  before  readmission  to  the  German  Hospital,  the  patient  noticed  a 
discharge  of  bile  which  continued  profusely  until  the  second  operation. 

Second  operation,  April  28,  191 1.  Ether  anesthesia.  Incision  made  around  old 
cicatrix,  and  the  fistulous  tract  dissected  down  to  the  gall-bladder.  The  gall- 
bladder was  removed,  and  all  the  ducts  e.xplored,  with  negative  result.  All  the 
ducts  were  patent,  and  no  calculi  were  present.  Patient  went  home  June  4,  1911, 
with  the  wound  entirely  healed. 

In  the  postoperative  biliary  fistula  a  more  serious  condition  is  present. 
Usually  there  is  an  obstruction  in  the  common  duct,  and  bile  is  dis- 
charged continuously  from  the  external  opening  of  the  hstula;  as  much 
as  1000  c.c.  (one  quart)  of  bile  may  be  lost  in  twenty-four  hours.  The 
deleterious  effects  of  complete  loss  of  bile  from  the  intestinal  tract  were 
studied  experimentally  in  dogs  by  Pawlow  in  1905 :  he  found  that  health 
was  rapidly  lost  and  bone  atrophy  occurred.  Seidel  (1910)  reported 
two  similar  cases  in  man.  But  if  the  discharge  is  not  very  profuse,  the 
patient  may  be  in  very  good  health,  although  in  most  cases  there  is  a 
certain  amount  of  indigestion,  and  the  patient  complains  of  feeling 
"miserable."  The  discomfort  caused  by  the  discharge  of  bile  usually 
is  so  great  that  operative  measures  should  be  instituted  for  its  reUef. 
But  in  a  certain  number  of  cases  external  drainage  of  bile  after  opera- 
tion acts  as  a  therapeutic  measure  in  relieving  the  angeio-cholitis  found 
at  operation,  and  by  permitting  a  subsidence  of  pancreatic  lymphan- 
geitis.  In  such  cases  it  may  be  necessary  to  wati  six  to  eight  months 
or  a  year  before  it  will  be  entirely  safe  to  restore  the  bile  to  the  intes- 
tinal tract;  and  before  this  time  has  elapsed  the  fistula  may  close  spon- 
taneously. So  long  as  bacteriological  examination  shows  the  biliary 
discharge  to  be  actively  infected,  we  beheve  it  is  inadvisable  to  under- 
take operation  for  its  relief.  Before  operation  is  adopted  even  in  cases 
where  the  discharge  proves  sterile,  it  is  well  to  try  irrigation  of  the 
tract.  In  this  way  it  often  is  possible  to  dislodge  calculi  which  may 
have  been  overlooked  at  the  time  of  operation,  or  which  may  have 
descended  from  the  intrahepatic  bile-ducts  since  that  time.  The  fluid 
used  for  irrigations  may  be  olive  oil,' or  a  0.5  per  cent,  solution  of  animal 
soap,  as  advised  by  Brockbank;  or  a  solution  of  turpentine  in  ether, 
as  recommended  by  Robson,  especially  when  the  obstruction  is  due  to 

the  presence  of  stones  or  fragments.     A  small  soft  catheter  is  passed 
34 


530  SURGERY    OF    THE    GALL-BL.\DDER    AND    BILE-DUCTS 

down  the  fistula  until  an  obstruction  is  encountered,  when  the  irrigating 
fluid  is  forced  gently  into  the  catheter  by  the  force  of  gravity,  or  from  a 
syringe. 

When  operation  is  undertaken,  the  fistulous  tract  shoud  be  dissected 
out  cautiously  until  the  peritoneum  is  opened.  Surrounding  structures 
are  then  packed  off,  and  the  dissection  continued  until  the  biliary  sys- 
tem is  exposed.  If  an  inoperable  obstruction  of  the  common  duct  is 
foimd,  the  surgeon  will  be  \ery  fortunate  if  a  reasonably  healthy  gall- 
bladder has  been  left  at  the  previous  operation,  since  it  may  now  be 
used  to  conduct  the  bile  into  the  intestinal  tract  by  means  of  a  cholecyst- 
enterostomy.  If  the  gall-bladder  has  already  been  removed,  or  if  it 
requires  removal  at  the  second  operation,  some  form  of  anastomosis  will 
now  have  to  be  made  between  the  common  or  hepatic  duct  above  the 
obstruction,  and  the  intestinal  tract  (page  515).  If  the  obstruction  of 
the  common  duct  can  be  removed,  this  should  be  of  course  done;  a 
calculus  may  be  extracted  or  pushed  into  the  duodenum;  a  stricture 
may  be  stretched  or  incised ;  a  benign  or  even  a  malignant  tumor  may 
be  extirpated.  Where  restoration  of  the  discharge  of  bile  through  the 
common  duct  can  be  secured,  the  gaU-bladder  should  be  removed. 
These  operations  never  are  easy,  and  may  be  very  difficult. 

BiLi.ARY  Fistula.  Cholecystectomy;  Choledochotomy.    Death 

B.  S.,  female,  aged  thirty-eight  years,  admitted  to  the  German  Hospital  Septem- 
ber 16,  1912,  with  a  histor>'  of  having  been  operated  upon  for  gall-stones  nine 
months  previously.  A  biliarj'  fistula  persisted.  There  had  been  no  attack  of  pain 
or  jaundice.  Bowels  had  been  regular,  but  the  stools  had  been  light  in  color,  soft 
and  of  foul  odor.     The  fistula  discharged  dark  brown  fluid  mi.xed  with  mucus. 

Operation,  September  iS,  1912.  Ether  anesthesia.  Scar  dissected  out.  Ad- 
hesions found  between  the  omentum,  gall-bladder,  under  surface  of  the  liver,  and 
the  abdominal  wall.  The  liver  was  adherent  to  the  parietal  peritoneum  and  could 
not  be  displaced,  .\dhesions  ligated  and  divided,  and  gall-bladder  exposed.  It 
was  of  good  size,  but  its  walls  were  markedly  thickened  and  a  stone  was  encysted 
in  its  wall.  Cholecystectomy.  Large  stone  found  in  common  duct.  Choledocho- 
tomy, stone  removed,  and  duct  drained.  Owing  to  the  fixity  of  the  liver  it  was 
impossible  to  ligate  the  cystic  artery  because  of  its  depth,  and  two  hemostats  were 
left  in  place.  Drain  placed  in  bed  of  gall-bladder  and  in  the  subhepatic  space,  and 
the  wound  in  the  abdominal  wall  partly  closed.  The  patient  did  not  react  from  the 
operation,  and  died  twenty-four  hours  later. 

Intestinal  Obstruction  from  Gall-stones 

Intestinal  obstruction  due  to  gall-stones  is  a  complication  or  sequel 
of  cholelithiasis  that  is  not  frequently  seen,  although  it  is  not  extremely 
rare.     Statistics  from  various  sources  show  that   gall-stones  are  the 


INTESTINAL    OBSTRUCTION   FROM    GALL-STONES  5,^1 

cause  of  from  2  to  4  per  cent,  of  cases  of  intestinal  obstruction.  In  a 
large  majority  of  cases  the  calculus  enters  the  intestinal  tract  through 
a  fistulous  opening  between  the  gall-bladder  and  duodenum. 

Porter  (1906)  suggested  the  following  as  a  convenient  classification 
of  cases  of  intestinal  obstruction  from  gall-stones:  Directly,  by  plugging 
or  corking  the  bowel  (obturation) :  indirectly,  (i)  by  causing  intestinal 
paresis;  (2)  by  the  production  of  volvulus;  (3)  by  producing  a  stricture  of 
the  intestine;  (4)  by  causing  spasmodic  contraction  of  the  circular  muscle 
fibers  of  the  bowel;  and  (5)  by  producing  angulation  of  the  bowel. 

The  most  frequent  cause  is  obturalion,  or  the  impaction  of  the 
calculus  in  the  intestine;  the  next  most  frequent  causes  are  volvulus 
caused  by  violent  peristaltic  movements  of  the  intestine  in  the  effort 
to  rid  its  lumen  of  the  obstructing  body;  and  strictures  the  result  of 
ulceration  caused  by  gall-stones  which  have  been  arrested  for  a  time, 
but  which  may  have  passed  by  rectum  long  before  the  stricture 
gives  rise  to  symptoms.  Occasionally  gall-stones  in  their  course 
through  the  intestinal  tract  may  become  lodged  in  diverticula.  Dr. 
Henry  Winsor  has  shown  us  photographs  of  the  specimens  from  a 
remarkable  case  which  came  under  his  observation  at  autopsy,  while  in 
Manila,  P.  I.  The  small  intestine  presented  innumerable  diverticula 
in  which  were  lodged  concretions  presumably  biliary  in  origin. 

Obstruction  from  obturation  by  gall-stones  may  occur  in  any 
portion  of  the  intestinal  tract  from  pylorus  to  anus.  As  the  small 
intestine  gradually  narrows  from  its  beginning  to  the  ileo-cecal  valve, 
the  position  of  the  obstruction  naturally  varies  with  the  size  of  the  stone. 
Large  calculi  are  arrested  higher  than  smaller,  and  the  latter  may  suc- 
ceed in  escaping  from  the  body  through  the  anus  after  causing  sHght 
or  partial  obstruction  at  various  times.  Very  small  calculi  may  be 
passed  without  producing  symptoms  of  obstruction  at  any  time.  A 
very  large  calculus,  measuring  43'^  by  3^^  inches  in  circumference  was 
found  impacted  in  the  ileum  in  a  case  recorded  by  Roberts  (1903),  and 
Baildon  (191 5)  removed  one  measuring  53^^  inches  in  circumference. 

According  to  Courvoisier's  statistics  (1890)  of  fifty-two  cases,  the 
site  of  impaction  was  in  the  duodenum  and  jejunum  in  21.4  per  cent.; 
in  the  ileum  in  65.4  per  cent.;  at  the  ileocecal  valve  in  10  per  cent.; 
and  in  the  sigmoid  flexure  in  2.4  per  cent.  LeBec  and  Mtiller  (1903) 
recorded  a  case  of  pyloric  obstruction  from  impaction  of  a  gall-stone. 

The  symptoms  are  those  of  intermittent  obstruction,  the  obstructing 
body  being  more  or  less  migratory.  When  obturation  occurs,  obstruc- 
tive symptoms  are  noted  at  once.  The  initial  symptoms  may  be  very 
mild.     Slight  colicky  pains,  quickly  subsiding,  and  leaving  the  patient 


532  SURGERY    OF    THE    GALL-BLADDER    AND   BILE-DUCTS 

apparently  in  perfect  health,  may  occur  for  many  hours  before  anything 
more  serious  is  noted.  Nausea  appears  early,  and  is  followed  by  vomit- 
ing. Distention  of  the  abdomen,  which  never  is  an  early  symptom, 
may  never  occur  at  all  if  the  obstruction  is  very  high  in  the  intestinal 
tract.  When  the  proximal  portion  of  the  bowel  becomes  very  much 
distended,  or  reversed  peristalsis  is  present,  the  calculus  may  slip 
backward  and  relieve  the  obstruction.  Under  such  circumstances 
the  symptoms  gradually  subside  and  the  patient  returns  to  an  appar- 
ently normal  condition;  but  will  again  become  a  victim  of  obstruction 
when  the  concretion  is  forced  down  into  a  portion  of  the  bowel  with 
lumen  too  small  to  accommodate  it. 

In  some  cases  the  calculus  can  be  felt  through  the  abdominal  walls 
as  a  round  or  slightly  oblong  hard  mass,  freely  movable,  and  devoid  of 
tenderness.  The  position  of  this  mass  may  be  in  any  portion  of  the 
abdomen  or  in  the  pelvis,  in  which  latter  position  it  may  readily  be 
mistaken  for  an  ovarian  neoplasm. 

The  diagnosis  of  gall-stone  obstruction  of  the  intestines  cannot 
be  made  with  certainty  in  most  cases  until  the  abdomen  has  been 
opened.  A  history  of  cholelithiasis,  if  obtainable,  a  history  of  previous 
similar  attacks  of  obstruction,  and  the  presence  of  a  more  or  less  mov- 
able hard  mass,  may  lead  to  a  recognition  of  the  true  condition. 

The  treatment  is  operative,  except  in  a  few  cases  where  the  symp- 
tions  of  obstruction  have  been  very  mild  and  not  of  long  duration. 
In  such  cases  it  may  be  advisable  to  temporize,  trusting  to  Nature  to 
expel  the  calculus.  Under  no  circumstances  should  purges  be  given. 
If  operation  is  not  required,  it  is  best  to  take  measures  to  check  peristal- 
sis by  administering  nothing  whatever  by  mouth,  by  applying  ice  to  the 
abdomen,  and  even  by  giving  morphin  hypodermically  in  the  hope 
that,  intestinal  spasm  being  relieved,  the  stone  may  pass  onward  with- 
out causing  further  trouble.  If  symptoms  of  obstruction  are  at  all 
severe,  however,  operative  treatment  should  be  undertaken  at  once. 
Unless  the  obstruction  can  be  accurately  localized  in  another  region, 
the  abdominal  incision  should  be  made  close  to  the  mid-line,  below  the 
umbilicus.  The  hand  is  then  introduced,  the  obstruction  sought  for, 
and  the  portion  of  intestine  involved  is  brought  out  of  the  wound  if 
possible,  and  well  walled  off  with  gauze.  If  the  obstruction  is  not 
readily  found  time  will  be  saved  by  evisceration.  If  the  stone  can  be 
dislodged  it  should  be  pushed  into  a  portion  of  the  bowel  that  is  free 
from  the  inflammatory  changes  caused  by  obstruction.  If  impacted 
in  the  lower  ileum  it  may  be  possible  to  push  it  through  the  ileocecal 
valve  and  to  work  it  through  the  colon  to  the  rectum,  whence  it  can  be 


INTESTINAL   OBSTRUCTION    FROM    GALL-STONES  533 

removed  by  an  assistant.  If  enterotomy  is  necessary  to  extract  the 
stone,  the  latter  should  be  held  firmly  against  the  wall  of  the  intestine 
opposite  the  attachment  of  the  mesentery  and  a  longitudinal  incision 
made  over  the  mass.  This  incision  should  be  just  large  enough  to 
allow  expulsion  of  the  calculus;  and  it  should  be  made  through  healthy 
bowel,  preferably  on  the  aboral  side  of  the  obstruction.  After  removal 
of  the  stone  the  intestinal  wound  should  be  closed:  (i)  with  a  continuous 
through-and-through  suture  of  catgut,  special  attention  being  paid  to 
inclusion  of  the  mucous  membrane  in  the  suture,  and  to  proper  inver- 
sion of  the  wound  margins;  (2)  this  first  row  of  sutures  should  then  be 
reinforced  with  a  continuous  sero-serous  suture  (Lembert  or  Gushing) 
of  fine  linen.  If  it  has  been  impossible  to  dislodge  the  calculus  it  may  be 
necessary  to  resect  the  segment  of  bowel  obstructed;  this  will  also  be 
necessary  if  gangerne  has  occurred  from  strangulation.  In  most  cases 
the  abdominal  wound  may  be  closed  without  drainage. 

The  high  mortality  of  this  condition  is  due  to  delay  in  resort- 
ing to  operation.  F.  Martin  (1912)  collected  nineteen  operations 
done  within  recent  years,  including  three  of  his  own.  Of  these  patients 
eight  recovered,  and  eleven  died,  a  mortality  of  57.8  per  cent.  All 
three  of  Martin's  own  patients  recovered,  though  in  one  resection  was 
necessary. 


CHAPTER  XVIII 
SURGERY  OF  THE  LIVER 

Anomalies  of  Size,  Shape,  and  Position  of  the  Liver 

These  may  be  congenital  or  acquired.  As  the  result  of  faulty  develop- 
ment, the  liver  may  enter  the  thoracic  cavity,  may  He  immediately 
beneath  the  skin  in  the  region  of  the  umbilicus  (hepatomphalos) ,  may 
form  part  of  the  contents  of  a  congenital  umbilical  hernia;  or,  finally, 
in  cases  of  transposition  of  the  viscera,  may  be  located  on  the  left  side 
the  body.  In  such  cases  the  left  lobe  is  larger  than  the  right.  Other 
congenital  anomalies  consist  in  absence  of  one  or  more  of  the  hgamenls; 
variation  in  the  size  of  the  lobes ;  or  the  presence  of  accessory  lobes.  In 
monsters  the  liver  may  be  absent.  Linguiform  lobulation  of  the  right 
lobe  may  be  found  as  a  congenital  defect;  such  cases  are  mistaken  at 
times  for  the  acquired  condition  described  by  Riedel  (page  535). 
Lobulation  or  other  change  in  the  configuration  of  the  entire  organ 
may  result  from  prenatal  sj'phihs,  tuberculosis,  or  hepatitis;  though 
it  is  more  likely  that  these  conditions  are  acquired  in  postnatal  life. 

Acquired  changes  in  the  form  of  the  liver  are  found  frequenth-. 
It  is  a  plastic  organ,  and  whenever  there  is  prolonged  abnormal  pres- 
sure or  traction  on  the  liver  substance,  lasting  changes  in  form  are 
produced.  The  principal  cause  of  these  acquired  changes  in  the  form 
of  the  organ  is  found  in  the  pressure  exerted  by  a  corset  or  band.  In 
the  classical  monograph  of  Hertz  (1894)  two  principal  forms  of  the  so- 
called  " corset-hver  "  are  described:  In  ihe  first,  one  or  both  lobes  are 
elongated  downward  in  the  form  of  a  thin  apron,  which  may  lie  over 
or  under  the  intestine ;  and  the  anterior  surface  of  the  Uver  is  marked  by 
a  transverse  depression  (the  "corset-furrow"),  the  overlying  peritoneum 
l)eing  thickened  and  fibrous.  In  the  second  form  the  upper  portion  of 
the  liver  is  much  thicker  than  the  lower.  The  posterior  surface  is 
curved  around  the  spinal  column  while  the  anterior  surface  conforms  to 
the  concavity  of  the  anterior  abdominal  wall.  The  transverse  corset- 
furrow  is  not  so  marked  as  in  the  first  tj^pe.  Mixed  types  may  also  be 
recognized. 

The  "corset-liver"  (Fig.  153)  is  seen  much  more  frequently  in 
women  than  in  men,  although  the  latter  are  not  free  from  it.     The 

534 


ANOMALIES    OF    FORM 


535 


change  in  shape  is  due  to  pressure  atrophy  of  the  liver  substance, 
followed  by  the  formation  of  cicatricial  tissue.  The  degree  of  alteration 
in  shape,  and  the  depth  of  the  furrow  vary  considerably  in  different 
cases.  In  some  instances  continued  pressure  will  cause  atrophy  of 
practically  all  of  the  hepatic  tissue  in  the  furrow,  nothing  but  a  hinge 
of  fibrous  tissue  remaining;  while  in  others  there  will  be  a  mere  indenta- 
tion on  the  convex  surface  of  an  otherwise  normal  liver. 

The  "  corset-Hver "  is  of  in- 
terest to  the  surgeon  mainly  as 
an  etiological  factor  in  diseases 
of  the  gall-bladder  and  bile- 
ducts.  This  aspect  of  the  con- 
dition was  discussed  at  page  478. 

Linguiform  lobulation  of  the 
liver  (Riedel's  lobe)  was  so 
graphically  described  by  Riedel 
in  1888,  that  his  name  has  be- 
come inseparably  connected 
with  the  condition.  It  had 
been  recognized  previously  and 
its  true  significance  perceived 
by  Terrier  (1888).  The  right 
lobe  is  the  usual  site  of  the  de- 
formity although  in  rare  cases 
the  quadrate,   or   even  the  left 

lobe  of  the  liver  has  been  affected.  In  the  typical  case  there  is  no 
ptosis  or  increased  mobility  of  the  Hver,  but  simple  elongation  or  hyper- 
trophy of  one  section  of  the  organ.  The  various  structures  holding  the 
liver  in  place  are  intact,  and  the  liver  maintains  its  normal  position 
against  the  diaphragm. 

Linguiform  lobulation  may  result  from  tight  lacing,  being  an 
extreme  degree  of  "corset-liver;"  but  usually  it  is  due  to  drag  upon 
the  liver  by  a  distended  gall-bladder,  and  in  almost  all  cases  is 
associated  with  disease  of  that  viscus.  According  to  Kelly  enlarge- 
ment of  the  gall-bladder  has  been  found  in  60  per  cent,  of  all  cases  of 
lobulation. 

A  Riedel's  lobe  varies  greatly  in  size  and  shape.  There  may  be  a 
scarcely  appreciable  elongation  downward  of  the  right  lobe,  or  a  freely 
movable,  distinctly  pedunculated  "wandering  lobe."  In  the  latter  in- 
stance the  pedicle  usually  is  attenuated,  being  httle  more  than  a  fibrous 
cord  which  attaches  the  lobe  to  the  liver.     Under  such  conditions  the 


r 


Fig.  1 53. — Corbet  Liver  from  a  Patient  in  the 
Episcopal  Hospital  Who  Died  from  Peritonitis 
Due  to  Perforation  of  a  Carcinomatous  Ulcer  of 
the  Stomach. 


536  SXJRGERY    OF    THE    LIVER 

lobe  will  be  very  freely  movable.  Riedel's  lobe  is  not  infrequently  the 
seat  of  gummata,  of  abscess  or  tumor. 

According  to  Harris  (1910),  Leue  in  a  total  of  3484  autopsies  found  a 
constricted  lobe  in  1.9  per  cent,  of  male  subjects  and  in  25.3  per  cent, 
of  female  subjects  over  si.xteen  years  of  age. 

The  symptoms  of  linguiform  lobulation  usually  are  those  of  an 
associated  condition  in  the  gall-bladder.  There  may  be  tenderness  and 
pain,  as  a  result  of  congestion  of  the  anomalous  lobe;  or  the  lobe  may 
exist  for  years  without  producing  any  symptoms.  Distortion  of  the 
duodenum  may  cause  dyspeptic  sjonptoms. 

Treatment. — This  consists  in  proper  treatment  of  any  biHary  lesion 
present.  Cholecystectomy  is  the  operation  of  choice;  the  liver  usually 
returns  to  its  normal  shape  after  this  operation.  If  no  cause  can  be 
found  to  account  for  the  development  of  the  linguiform  lobe,  it  may  be 
excised,  or  sutured  to  the  anterior  abdominal  wall. 

Acute  passive  congestion  of  the  liver,  associated  with  cardiac  in- 
competency, may  simulate  very  closely  an  attack  of  acute  cholecystitis. 
The  enlarged  liver  is  extremely  tender,  there  is  rigidity  of  the  over- 
lying abdominal  wall,  the  patient  suffers  great  pain,  appears  acutely 
ill,  is  nauseated,  and  there  is  leukocytosis.  But  the  association  of 
dyspnea  and  the  physical  examination  of  the  heart  should  put  the  sur- 
geon on  his  guard. 

Hepatoptosis,  movable  liver  or  floating  liver  ma>'  be  congenital  or 
acquired. 

Congenital  movable  liver  may  be  due  to  the  presence  of  a  mesohepar, 
as  in  the  case  reported  by  Clark  and  Dolley  (1905).  Their  patient  was 
a  female,  thirty-four  years  of  age.  and  unmarried.  Her  abdomen  was 
markedly  asymmetric,  there  being  a  definite  bulging  of  the  right  side 
from  the  costal  margin  to  the  iliac  crest.  The  lower  lobe  had  no  liga- 
ments, and  there  was  a  double  reflection  of  the  peritoneum  from  the 
upper  lobe  to  the  diaphragm,  producing  a  true  meso-hepar,  which 
measured  13  mm.  in  length.  Albu  (1909)  studied  ninety-four  infants 
ranging  from  one  to  ten  da^^s  old,  and  found  visceral  ptosis  in  11  per 
cent,  of  the  males  and  44  per  cent,  of  the  females;  hepatoptosis  was 
present  in  5  per  cent,  of  the  males  and  in  9  per  cent,  of  the  females. 

Acquired  movable  liver,  which  was  first  noted  by  Heister  in  1754  in 
his  study  of  a  cadaver,  and  first  described  in  the  living  subject  by 
Cantani  in  1866,  is  not  a  very  rare  condition.  Clarke  and  Dolley 
(1905)  found  reports  of  118  cases;  this  included  those  collected  by 
Legg,  Faure,  Graham,  and  Ssaweljew.  Of  these,  thirteen  were  in 
men  and  103  in  women,  and  one  in  a  child.     Of  the  women,  ninety- 


HEPATOPTOSIS  537 

three  were  married  and  ten  single.  In  a  study  of  3400  patients, 
about  equally  divided  as  to  sex,  Albu  (1Q09)  found  visceral  ptosis 
in  21  per  cent,  of  the  men  and  68  per  cent,  of  the  women;  hepatoptosis 
was  found  in  9  per  cent,  of  men  and  17  per  cent,  of  women. 

The  liver  is  naturally  a  mobile  organ,  moving  upward  and  down- 
ward with  the  ordinary  respiratory  movements  and  also,  to  a  slight 
degree,  with  posture.  Normally,  the  liver  is  held  in  position  by  the 
inferior  vena  cava  and  the  hepatic  veins  which  empty  into  it;  by  the 
coronary  hgaments  and  their  cellulo-vascular  bands;  by  the  fibrous 
tissue  found  on  the  posterior  extra-peritoneal  surfaces;  by  the  intra- 
abdominal pressure  exerted  by  the  muscles  of  the  abdominal  wall; 
by  the  so-called  suspensory  ligaments;  and  by  negative  intrathoracic 
pressure.  Anything  which  decreases  the  sustaning  powers  of  these 
various  agencies  or  markedly  increases  the  amount  of  work  thrown 
upon  them  may  be  a  factor  in  causing  displacement  of  the  organ. 
The  causes  may  be  divided  into  the  following  classes:  (i)  traumatic; 
(2)  conditions  producing  increased  intra-abdominal  capacity,  such 
as  repeated  pregnancies  when  associated  with  pendulous  abdomen, 
removal  of  tumors  or  ascitic  fluid,  etc.;  (3)  structural  increase  in  the 
size  of  the  hver,  or  solid  growths  dragging  on  the  organ;  and  (4)  the 
use  of  improperly  fitting  corsets.  Downward  traction  may  be  exerted 
by  an  abnormally  shortened  round  ligament.  Cheyne  (1906)  believed 
that  "once  the  liver  is  displaced  downward  from  the  diaphragm  it 
is  sucked  down  still  more  by  the  atmospheric  pressure  and  the 
intestines  pass  up  between  it  and  the  diaphragm."  When  Heister, 
in  1754,  found  a  movable  liver  at  autopsy,  he  advanced  the  theory 
that  the  development  of  the  condition  "was  due  to  the  will  of  God  to 
prove  his  Omnipotent  power." 

Landau  (1885)  divided  cases  of  hepatoptosis  into  three  grades  or 
degrees.  In  the  first  grade  there  is  moderate  descent  combined  with 
version,  either  anterior  or  posterior.  In  the  second,  there  is  marked 
descent  combined  with  lateral  displacement  toward  the  right  and 
version  either  anterior  or  posterior:  In  the  third  there  is  displacement 
directly  downward,  or  slightly  oblique,  with  the  left  lobe  usually  pal- 
pable in  the  abdominal  cavity.  The  liver  may  also  be  displaced 
upward,  with  rotation,  so  that  the  inferior  surface  will  present 
anteriorly. 

The  same  factors  which  cause  changes  in  the  position  of  the  liver 
frequently  have  a  similar  effect  on  the  other  organs  of  the  abdominal 
cavity.  In  consequence  of  this  a  general  splanchnoptosis  usually  is 
associated  with  movable  liver.     T.  R.  Brown  (1908)  quoted  Glenard 


5,s8  SURGERY   OF    THE    LIVER 

as  having  found,  in  a  study  of  1310  patients,  fifty-one  cases  of  hepa- 
toptosis,  thirty-two  of  which  were  associated  with  movable  kidney. 

Temporary  displacement  of  the  liver  must  not  be  confounded 
with  movable  liver,  although  the  latter  condition  may  be  estab- 
lished ultimately.  Such  temporary  displacement  not  infrequently 
is  produced  by  pressure  from  pathological  lesions  distinct  from  the 
liver.  Pressure  may  be  exerted  in  a  downward  direction  by  intra- 
thoracic conditions  such  as  pleurisy  with  exudate,  empyema,  hydro- 
thorax,  or  emphysema;  by  tumors  or  abscesses  of  the  lungs  or 
mediastinum;  or  by  pathological  changes  between  the  diaphragm 
and  the  hver,  such  as  subphrenic  abscesses.  Upward  displacement 
may  result  from  disease  of  the  abdominal  organs,  especially  when 
associated  with  ascites.  A  traumatic  opening  through  the  diaphragm 
may  allow  the  liver  to  become  involved  in  a  diaphragmatic   hernia. 

The  resulting  degree  of  mobility  of  the  liver,  after  the  subsidence  ol 
these  various  affections,  will  be  modified  by  the  extent  and  duration 
of  the  pressure  exerted  and  by  the  strength  and  abundance  of  the 
resulting  adhesions. 

The  symptoms  of  movable  hver  are  rather  vague.  In  many  cases 
the  sjTiiptoms  presented  by  the  displaced  liver  are  over-shadowed  by 
those  of  the  diseases  causing  the  trouble.  In  all  of  these  cases  the 
displaced  liver  is  of  secondary  importance.  In  movable  liver  pain 
frequently  will  be  the  first  symptom  noticed.  This  pain  may  begin 
as  the  result  of  any  jarring  movement  of  the  body,  or  anything  causing 
a  sudden  spasmodic  contraction  of  the  diaphragm.  The  pain  may 
be  noticed  first  after  jumping,  sneezing,  coughing,  etc.  Later,  parox- 
ysms of  pain  may  occur  without  any  known  cause.  The  pain  is  most 
commonly  felt  in  the  right  hypochondrium  and  epigastrium  but  it 
may  radiate  to  the  right  shoulder  or  to  the  right  flank.  The  pain 
is  relieved  almost  immediately  by  replacement  of  the  Hver  in  its 
normal  position.  Pressure  on  the  liver,  when  ptosed,  causes  peculiar 
sensations  in  various  parts  of  the  body,  especially  in  the  arms  and 
shoulders.  Digestive  symptoms  vary.  Usually  symptoms  of  gastric 
dyspepsia  are  present;  especially  flatulence,  discomfort  during  the 
the  period  of  digestion,  vague  pains  in  the  epigastrium  and  often 
throughout  the  intestinal  tract,  headache,  insomnia,  etc.  There 
is  a  feehng  of  weight  and  hea\aness  in  the  epigastrium  and  hepatic 
region.  Sometimes  there  maj-  be  found  also  ascites,  polyuria,  hemor- 
rhoids, jaundice,  recurring  hemorrhages  from  the  stomach  and  edema 
of  the  lower  limbs.  A  caput  medusa  may  be  found  as  a  result  of 
traction    on    the    vena    cava.     As    a    rule,   there    is   no  marked   dis- 


HEPATOPTOSIS  539 

turbance  of  the  normal  biliary  activity,  though  gall-stones  often  are 
present. 

The  diagnosis  of  hepatoptosis  is  based  on  the  symptoms  men- 
tioned, together  with  a  demonstration  of  the  displacement.  The 
proptosed  liver  will  be  recognized  as  a  large  tumor  in  the  abdomen, 
of  the  size  and  consistency  of  the  Uver;  usually  it  is  to  the  right  of 
the  umbilicus,  and  often  a  distinct  notch  can  be  felt.  The  tumor 
may  be  partly  replaced  toward  its  normal  position  where  it  will  remain 
while  the  patient  is  recumbent.  When  it  is  displaced,  percussion 
of  the  normal  site  of  the  liver  will  give  a  tympanitic  note  rather  than 
the  usual  dull  or  flat  liver  note,  and  the  pulmonary  resonance  poste- 
riorly will  merge  with  intestinal  resonance.  It  may  be  distinguished 
from  a  movable  or  enlarged  kidney  by  the  absence  of  urinary  symp- 
toms; by  observing  that  the  liver  moves  during  respiration;  that  it 
lies  in  front  of  the  colon,  not  behind  it;  and  by  attention  to  the  changes 
in  the  percussion  note  in  the  normal  hepatic  area,  to  which  attention 
already  has  been  directed.  Fluoroscopic  examination  should  be 
made  or  an  x-ray  photograph  should  be  obtained  for  confirmatory 
evidence. 

The  treatment  is  palliative  or  operative.  Palliative  treatment 
consists  in  the  appHcation  of  a  well-fitting  binder  or  abdominal  bandage 
which  will  retain  the  organ  in  its  normal  site  after  it  has  been  replaced 
by  manipulation.  The  pressure  should  always  be  from  below  upward 
the  intestines  being  pushed  upward  to  act  as  a  cushion  on  which  the 
liver  may  rest.  The  inflatable  pad  of  Byron  Robinson  (1903)  is  a  good 
apparatus  for  this  purpose. 

Operative  treatment  consists  in  retaining  the  liver  in  its  normal 
position  by  one  of  the  numerous  methods  of  hepatopexy  that  have 
been  devised.  In  replacing  the  liver  the  organ  should  be  rotated 
backward  and  to  the  right,  and  pushed  well  up  against  the  diaphragm, 
after  examination  of  the  space  between  the  hver  and  diaphragm  has 
shown  that  no  coil  of  intestine  Kes  between. 

The  first  operation  of  hepatopexy  was  performed  by  Gerard- 
Marchant  in  1891.  He  sutured  the  anterior  edge  of  the  liver  to  the 
costal  margin  with  silk.  Pean  held  the  Hver  in  its  normal  site  by  first 
making  a  transverse  abdominal  incision,  replacing  the  liver,  and  then 
making  a  barrier  below  it  by  suturing  the  anterior  and  posterior  layer 
of  parietal  peritoneum  together  transversely.  Franke  united  the  ante- 
rior margin  of  the  liver,  with  the  exception  of  the  portion  near  the  gall- 
bladder ,  to  the  costal  margin  and  then  placed  gauze  between  the  upper 
surface  of  the  liver  and  the  diaphragm.     The  gauze  was  allowed  to 


540  SURGERY    OF    THE    LU^ER 

remain  in  place  for  eight  days.  Its  removal  was  followed  by  the  forma- 
tion of  strong  adhesions  between  the  liver  and  diaphragm.  Moynihan 
advocated  the  same  line  of  procedure,  with  the  addition  of  gauze  pack- 
ing placed  below  the  right  lobe  of  the  liver.  Cheyne  sponged  the  upper 
surface  of  the  Uver  with  undiluted  carboUc  acid.  He  also  recommended 
division  of  the  round  ligament  when  that  structure  seems  too  short. 
In  all  forms  of  operation  the  patient  must  remain  on  the  back  in  bed  for 
at  least  four  weeks,  at  absolute  rest.  Elevation  of  the  foot  of  the  bed  a 
few  inches  will  also  aid  in  overcoming  any  tendency  of  the  Hver  to 
prolapse  during  the  formation  of  strong  adhesions.  For  some  months 
after  operation  a  well-fitting  abdominal  belt  or  binder  should  be  worn 
and  all  \'iolent  efforts  should  be  carefully  avoided. 

Abscess  of  the  Liver 

Abscess  of  the  liver  (suppxirative  hepatitis)  may  be  classified 
in  various  ways:  as  single  or  multiple;  as  tropical  (amebic)  or  non- 
tropical; as  primary  (traumatic)  or  secondary;  according  to  the  charac- 
ter of  the  infecting  micro-organism;  or  according  to  its  location,  the  "anato- 
mical" classification. 

Probably  the  best  classification  is  that  which  recognizes  i .  Traiuna- 
tic  abscess,  in  which  there  is  a  wound  or  contusion  of  the  liver  substance 
followed  by  infection  from  the  exterior  or  from  the  blood.  2.  Pyemic 
(embolic  abscess,)  in  which  infection  reaches  the  liver  by  means  of 
infected  emboU,  through  extension  of  suppurative  processes  adjacent 
to  the  liver,  by  direct  infection,  etc.  3.  Amebic  (tropical)  abscess, 
in  which  the  ameba  coli  is  the  chief  etiological  factor.  Rarer  forms 
of  abscess  in  which  the  liver  becomes  honey-combed  with  cavities  con- 
taining pus  and  varying  in  size  from  a  pea  to  a  walnut,  sometimes 
larger,  are  due  to  tuberculosis,  or  actinomycosis  Suppuration  also 
frequently  occurs  in  an  hydatid  cyst  (page  559). 

Etiology.  Predisposing  Causes. — Traumatic  abscess,  as  its  name 
imphes  always  is  preceded  by  a  wound  or  contusion  involving  the 
integrity  of  the  liver  ceUs.  In  cases  of  penetrating  wound,  by  stab  or 
gunshot  injury,  or  when  the  liver  is  punctured  by  the  fragment  of  a 
rib  in  compound  fracture,  the  infection  is  admitted  from  without.  In 
cases  of  contusion,  or  subcapsular  rupture  of  the  liver,  the  hematoma 
which  forms  may  be  converted  into  an  abscess  by  infection  through  the 
blood,  or  lymphatics,  or  even  through  the  biliary  tract  (page  545). 
Pyemic  abscess  may  have  as  a  predisposing  cause  any  suppurative, 
infectious,  or  parasitic  condition  in  any  portion  of  the  body.     Espe- 


ABSCESS    OF    THE    LIVER 


541 


daily  frequent  are  lesions  in  the  distribution  of  the  portal  vein,  such 
as  appendicitis  or  typhoid  fever. 

Melchior  (1910)  gave  the  following  figures  showing  the  frequency 
with  which  typhoid  fever  is  complicated  by  hepatic  abscess. 


Author 

Cases  of  liver 
abscess 

Cases  of  ty- 
phoid fever 

Percentage 

Holscher 

12 

2 
2 

3 
0 

2000 

1229 
1 186 

1662 

0.6 
0.58 
0. 16 
0.2s 

Piorkowsky 

Vierhuflfs 

Berg 

The  hepatic  abscess  usually  develops  during  convalescence  from  typhoid 
fever,  but  a  year  has  elapsed  in  some  cases.  The  average  fever-free 
interval  is  fourteen  days — the  period  between  defervescence  from 
typhoid  fever  and  the  development  of  symptoms  from  the  hepatic 
abscess.  The  infection  may  reach  the  liver  through  the  bile-ducts, 
through  the  systemic  circulation,  or  by  way  of  the  portal  vein.  Four 
cases,  all  fatal,  followed  appendicitis  of  typhoidal  origin.  Melchior 
collects  records  of  twenty-five  cases,  in  none  of  which  no  operation  was 
done.  Of  these  nine  patients  only  two  recovered,  the  abscess  in  the 
first  case  (1869)  discharging  spontaneously  through  the  lung,  and  that 
of  the  second  pateint  (1875)  rupturing  through  the  bowels.  In  four 
cases  no  formal  operation  was  done,  the  abscess  merely  being  punctured ; 
all  of  these  patients  died.  Of  twelve  patients  in  whom  the  abscess  was 
treated  by  incision,  in  the  ordinary  way,  only  two  died,  a  mortality 
of  17  per  cent.  This  clearly  demonstrated  that  the  proper  treat- 
ment of  hepatic  abscess  in  typhoid  fever  is  by  operation,  according 
to  the  usual  technique  (Chapter  XXIV). 

As  regards  hepatic  abscess  of  appendicular  origin,  il  usually  has  been 
taught  that  the  foci  of  suppuration  in  the  liver  are  multiple  and  wide- 
spread; and  there  is  no  doubt  that  this  is  so  in  most  cases,  and  that 
the  condition  is  exceedingly  fatal.  Personally  we  never  have  seen 
recovery  occur  in  a  case  of  hepatic  abscess  secondary  to  appendicitis; 
but  such  cases  have  been  reported  in  a  few  instances.  Quenu  and 
Mathieu  (191 1)  note  that  although  foci  of  suppuration  in  almost 
all  these  cases  are  multiple,  yet  that  some  patients  have  had  only  one 
or  at  most  two  solitary  abscesses,  and  that  in  other  cases  the  abscesses, 
even  if  multiple,  are  closely  congregated  in  the  right  lobe  of  the  liver 


542  SURGERY   OF  THE   LIV'ER 

and  should  be  amenable  to  operative  treatment.  Loison,  in  1900, 
reported  twelve  such  cases,  all  the  pateints  having  died  without  opera- 
tion because  the  possibility  of  cure  by  operation  was  not  recognized. 
Loison  reported  one  patient  under  his  own  care,  whose  life  was  saved 
by  timely  operation,  and  he  says  that  Korte  in  1892  also  had  one 
patient  who  recovered  after  operation.  We  are  inclined,  however,  to 
agree  with  Tuffier,  who  in  the  discussion  which  followed  the  reading  of 
Loison's  report  said  that  to  him  the  diagnosis  in  Loison's  patient  seemed 
uncertain;  it  might  have  been  a  case  of  subphrenic  abscess  following 
appendicitis.  Quenu  and  Mathieu  collected  records  of  fourteen  opera- 
tions for  this  complication  of  appendicitis,  with  only  two  deaths.  The 
cases  suitable  for  surgical  intervention  are  not  those  presenting  the 
usual  picture  of  diffuse  suppurative  hepatitis  or  pylephlebitis  closely 
following  the  attack  of  appendicitis,  but  those  in  which  the  symptoms 
of  liver  abscess  develop  after  a  free  interval,  and  in  which  the  physical 
signs  indicate  that  a  single  abscess  may  be  present.  The  operative 
methods  in  these  cases  are  the  same  as  in  cases  of  tropical  abscess  of 
the  liver  (p.  791). 

Abscesses  as  a  result  of  suppurative  processes  in  tltc  structures  adjacent 
to  the  liver  are  not  common.  They  may  follow  acute  empyema  of  the 
gall-bladder,  perforation  occurring  through  the  portion  of  that  viscus 
which  is  in  contact  with  the  liver  substance.  Direct  extension  from  dis- 
eased conditions  of  the  pylorus  and  pancreas,  after  the  formation  of 
adhesions  binding  these  structures  to  the  liver,  may  result  in  infection 
and  abscess  formation  in  the  Hver;  but  this  is  rare.  Liver  abscess  due 
to  suppurative  cholangeitis  almost  invariably  is  multiple  and  a  sequel  of 
lesions  of  the  biliary  apparatus  (Plate  VII).  Theoretically  it  is  possible 
for  such  intestinal  affections  as  typhoid  fever,  gastroduodenitis,  duo- 
denal ulcer,  etc.,  to  infect  the  bile-duct  by  continuity  of  structures, 
but  in  almost  all  such  cases  it  is  quite  evident  that  the  foci  of  suppura- 
tion in  the  liver  are  due  to  septic  emboli  received  through  the  portal 
system  or  by  way  of  the  systemic  circulation,  as  in  pyemia. 

Liver  abscess  has  been  shown  to  follow  influenza,  yellow  fever  and 
many  other  infectious  diseases.  Suppurative  venous  thrombosis  with 
the  production  of  septic  emboh  and  abscess  of  the  liver  may  follow 
almost  any  infective  process  in  the  body  either  by  way  of  the  porta!  or 
the  systemic  circulation.  These  predisposing  causes  were  well  sum- 
marized by  Munro  (1905),  as  follows:  "Malaria,  infections  of  the  thor- 
acic organs  or  of  the  umbilicus,  pyemia  arising  from  various  infections 
of  any  portion  of  the  body,  anthrax,  ulcers  of  the  intestinal  tract, 
pelvic  infections,   splenic  abscess,  abscess  of  the  mesenteric  lymph- 


ABSCESS    OF    THE    LRER  543 

nodes,  infections  of  the  biliary  tract  and  pancreas,  from  peritonitis, 
echinoccoccus,  infection  after  hemorrhoidal  operations,  etc." 

McWilliams  (1907)  in  an  analysis  of  sixteen  cases  of  abscess  of  the 
liver  found  that  ten  of  them  exhibited  no  apparent  or  evident  etiological 
factor. 

Climate. — Chmate  plays  a  very  important  part  as  a  predisposing 
cause  of  amebic,  or  tropical,  abscess.  It  is  a  change  of  climate,  how- 
ever, rather  than  the  climate  itself  which  is  the  important  factor. 
Tropical  dysentery,  which  is  so  frequently  the  forerunner  of  abscess 
of  the  liver,  occurs  most  frequently  among  those  who  go  to  the  tropics 
from  a  temperate  climate;  and  especially  among  those  who  do  not 
conform  to  the  diet  and  customs  of  the  tropics.  Herrick  (1910)  from 
a  study  of  abscess  of  the  liver  in  the  Panama  Canal  Zone,  estimated 
that  the  white  man  from  the  United  States  is  the  most  susceptible  of 
all  laborers,  and  that  the  colored  employees  from  the  islands  are  the 
least  susceptible.  He  found  one  case  in  every  11 78  whites  from  the 
United  States;  one  case  in  every  2240  whites  from  Europe;  and  one 
case  in  every  3722  colored  employees.  Kieffer  (1903)  studied  thirty- 
three  cases  of  liver  abscess  among  the  soldiers  in  the  Phillippines,  and 
found  a  history  of  dysentery  in  each;  among  twenty-live  cases  of 
abscess  among  the  natives  and  civilians  there  was  a  history  of 
dysentery  in  twenty-two.  Keiffer  concluded  from  his  investigations 
that  20  to  25  per  cent,  of  the  cases  of  severe  amebic  dysentery  result  in 
liver  abscess;  and  that  85  per  cent,  of  tropical  abscesses  are  due  to  the 
ameba. 

The  frequency  of  tropical  abscess  as  a  result  of  dysentery  varies 
with  the  statistics  of  dilYerent  countries.  In  India,  about  35  per  cent, 
of  the  soldiers  who  died  from  dysentery  had  pus  in  the  liver,  while 
liver  abscess  was  found  in  less  than  5  per  cent,  of  the  patients  in  the 
Philippines  who  suffered  from  dysentery  (Rhoads,  1904).  It  is  safe  to 
assume  that  all  cases  of  amebic  abscess  of  the  liver  have  been  preceded 
by  a  dysenteric  ulceration  of  the  intestine.  In  those  cases  where 
causal  relation  cannot  be  determined,  either  the  symptoms  of  dysentery 
were  so  slight  that  the  patient  forgot  all  about  them,  or  the  ulcerations 
were  slight  and  the  condition  ran  a  latent  course  without  the  production 
of  marked  symptoms. 

Coffin  (1906)  found  1523  cases  of  dysentery  among  10,603  patients 
treated  in  the  United  States  Army  Division  Hospital  in  Manila  in 
three  and  one-half  years.  Of  these,  859  were  of  the  amebic  type;  236 
were  of  the  catarrhal  type;  and  in  428  cases  the  type  was  not  noted. 
The  majority  of  cases  were  sent  home  invalided,  in  from  one  to  eight 


544  SURGERY    OF    THE    LR'ER 

weeks,  this  fact  accounting  for  the  small  number  of  liver  abscesses 
found,  thirty-four. 

The  disease  is  particularly  prevalent  in  the  Philippine  Islands, 
India,  and  Egypt. 

Exciting  Causes. — All  abscesses  of  the  liver  are  the  result  of  bacterial 
or  parasitic  invasion.  Foreign  bodies,  such  as  fish-bones,  pieces  of 
straw,  etc.,  have  been  found  in  the  contents  of  the  abscess  cavity, 
but  it  is  probable  that  the  abscess  resulted  from  the  presence  of  micro- 
organisms and  was  not  caused  by  the  foreign  body  alone.  Coccidia 
and  the  ray  fungus  of  actinomycosis  have  been  underlying  factors;  in 
rare  instances  the  bacillus  of  tuberculosis  may  act  as  the  direct  causa- 
tive factor. 

Bacteria  may  gain  entrance  to  the  liver  through  a  wound  communi- 
cating with  the  exterior  of  the  body;  through  extension  of  suppurative 
conditions  in  the  adjacent  structures;  through  the  portal  vein,  the 
hepatic  artery,  the  hepatic  vein,  or  the  lymphatics  from  adjacent  or 
far  distant  points  of  infection;  or  through  the  biliary  passages.  The 
most  frequent  pathway  of  entrance  is  through  the  portal  vein,  the 
radicals  of  which  carry  the  infection  from  more  or  less  distant  foci.  In 
other  than  tropical  climes  the  most  frequent  source  of  infection  is  found 
in  disease  of  the  appendix ;  in  tropical  countries  the  infection  most  fre- 
quently is  a  sequel  of  dysentery. 

The  micro-organisms  which  are  found  most  frequently  in  liver 
abscesses  are  the  Amoeba  coli,  the  B.  coH,  the  streptococcus,  the  B. 
pyocyaneus,  the  B.  dysenterije,  the  D.  pneumonia?,  the  Actinomyces 
bovi,  the  S.  pyogenes  aureus  and  albus,  and  B.  typhosus. 

Pathology. — Liver  abscess  may  be  solitary  or  multiple.  Trau- 
matic and  amebic  abscesses  usually  are  single;  pyemic  (embolic)  and 
tuberculous  abscesses  usually  are  multiple.  The  majority  of  abscesses 
develop  in  the  right  lobe  of  the  liver,  and  usually  are  nearer  the  convex 
than  the  concave  surface.  They  vary  greatly  in  size,  from  minute  foci 
to  collections  of  pus  that  may  occupy  the  greater  part  of  the  entire 
organ. 

The  pathological  changes  found  in  the  liver  vary  with  the  underlying 
etiological  factors  causing  the  abscess.  The  contents  of  the  abscess 
maj'  vary  in  color  from  yellow  to  green  or  brown;  in  almost  all  cases 
microscopical  study  reveals  the  presence  of  bacteria  in  addition  to  liver 
cells  and  detritus,  which  are  always  present.  The  bacteria  usually 
found  are  streptococci,  staphylococci  and  colon  bacilli.  The  walls  of 
the  abscess  cavity  are  irregular  and  are  composed  of  infiltrated  liver 
substance. 


ABSCESS    OF    THE    LIVER  545 

Traumatic  abscess  always  is  septic.  When  there  is  a  subpari- 
etal  injury,  the  bacteria  of  suppuration  may  be  introduced  into  the 
devitaUzed  portion  of  the  liver  either  through  the  bile-channels,  the 
portal  vein,  the  hepatic  artery  or  the  hepatic  veins,  or  directly  from 
the  liver  substance  where  there  has  been  previous  disease  of  the  organ. 
When  there  is  an  external  communication  with  the  liver  the  germs  of 
suppuration  usually  are  introduced  through  this  channel,  frequently  as 
a  result  of  unnecessary  probing  and  examination  of  the  wound.  The 
site  of  an  abscess  following  trauma  is  determined  by  the  site  of  the  in- 
jury. The  size  varies  with  the  extent  of  the  injury  and  the  virulence  of 
the  infecting  micro-organism. 

Ill  embolic  or  pyemic  abscesses,  which  comprise  those  usually  seen  in 
temperate  climes,  the  process  is  somewhat  different  from  that  found  in 
the  traumatic  abscess.  Emboli  carrying  germs,  lodge  in  one  or  more  of 
the  terminations  of  the  portal  vein,  with  resulting  congestion,  liquefac- 
tion and  purulent  degeneration  of  the  liver  substance.  In  many  in- 
stances the  emboli  may  be  carried  to  the  liver  through  the  hepatic 
artery,  the  emboli  passing  through  the  capillaries  of  the  lung,  entering 
the  left  side  of  the  heart,  and  then  being  carried  with  the  arterial  stream 
to  the  liver  or  other  organs  where  abscesses  are  formed.  It  is  probable 
that  actual  emboli  do  not  pass  through  the  pulmonary  capillaries,  but 
that  clumps  of  bacteria  are  carried  into  the  systemic  circulation,  and 
that  these,  when  they  are  arrested  in  the  next  set  of  capillaries,  or 
when  they  reach  a  situation  favorable  to  their  growth,  there  induce 
thrombosis  and  suppuration. 

Pyemic  (embolic)  abscesses  usually  are  multiple  and  may  occupy 
any  portion  of  the  liver  substance,  although  they  are  found  most  fre- 
quently in  the  right  lobe.  They  generally  are  near  the  surface  of  the 
liver  and  vary  in  size  from  minute  foci  of  suppuration  to  masses  the 
size  of  an  entire  lobe.  Small  foci  frequently  coalesce  to  form  large 
abscesses.  Microscopical  examination  of  the  contents  of  embolic 
abscesses  shows  the  presence  of  active  bacteria  in  all  instances.  The 
liver  substance  surrounding  the  suppurating  process  always  shows 
inflammatory  changes. 

In  the  tropical  or  amebic  liver  abscess,  the  destructive  process  is  said 
to  begin  in  the  hepatic  cells.  This  process  sometimes  begins  immedi- 
ately after  the  onset  of  amebic  dysentery;  but  in  most  cases  weeks, 
months,  or  even  years  elapse  before  the  destructive  process  is  manifest. 
Musgrave  and  Clegg  (1904)  estabhshed  the  fact  that  amebas  are  amen- 
able to  changes  in  environment  and  that  the  power  to  propagate  in 

temperate  climes  depends  on  the  similarity  to  the  old  environment,  and 
35 


546  SXJRGERY    OF    THE    LIVER 

possibly  on  their  ability  to  produce  lesions  in  the  tissues.  The  develop- 
ment of  the  abscess  may  be  very  slow. 

Purulent  softening  causes  coalescence  of  adjacent  acini  until  the 
destructive  process  may  involve  an  entire  lobe  of  the  Uver.  The 
abscesses  are  soUtary  in  about  60  per  cent,  of  the  cases,  and  are  most 
frequently  found  in  the  right  lobe.  Among  240  cases  studied  by 
Waring,  the  right  lobe  was  affected  in  163.  Rouis  (i860),  in  an  analy- 
sis of  1 56  cases,  found  the  abscess  in  the  right  lobe  in  1 2  2 ;  and  Musgrave 
and  Clegg  (1904)  found  the  right  lobe  involved  in  95  per  cent,  of  their 
cases.  Langenbuch  (1894)  explained  this  preference  for  the  right  lobe 
by  the  distribution  of  the  branches  of  the  portal  vein.  The  branch 
going  to  the  right  lobe  is  larger  than  that  to  the  left,  and  runs  parallel  to 
the  course  of  the  vein,  while  that  to  the  left  lobe  runs  at  right  angles. 
The  separate  currents  in  the  portal  vein  were  alluded  to  at  page  42; 
the  fact  that  most  of  the  usual  foci  of  infection  are  in  the  area  which 
drains  into  the  right  lobe  is  another  reason  for  the  frequency  with  which 
this  portion  of  the  Hver  is  affected. 

When  the  abscess  is  within  the  right  lobe  the  liver  may  be  normal  on 
inspection  even  if  the  abscess  is  large.  Distinct  elevation  will  be 
noticed  as  the  abscess  nears  the  surface.  Peritoneal  irritation  usually 
is  followed  by  the  formation  of  adhesions  between  the  hver  and  the 
abdominal  wall,  the  adjacent  viscera,  or  the  diaphragm.  In  many 
cases  some  evidences  of  pleuritis  are  found. 

Amebic  abscesses  vary  in  size  from  minute  foci  of  pus  to  a  col- 
lection the  size  of  the  hver  itself;  almost  the  entire  Uver  may  be  con- 
verted into  a  sac,  and  as  much  as  8000  c.c.  have  been  removed  from 
such  a  sac. 

The  contents  of  the  amebic  abscess  vary  with  the  duration  of  the 
infection  and  with  the  extent  of  the  destructive  process.  The  con- 
sistency varies  from  fluid  to  gelatinous.  The  color  usually  is  brown. 
As  a  rule,  bile  is  not  a  constituent  of  the  abscess,  the  contents  being 
composed  almost  exclusively  of  liver  cells  and  detritus.  In  cases  of 
very  long  duration,  yellow  pus  may  be  found. 

Microscopical  examination  usually  reveals  amebae,  especially 
in  specimens  obtained  from  the  walls  of  the  abscess.  Kieffer  (1903) 
was  able  to  demonstrate  neither  bacteria  nor  amebae  in  20  per  cent,  of 
his  cases;  in  60  per  cent,  bacteria  were  present  at  the  time  of  his  exami- 
nation. The  amebae  are  demonstrable  in  the  majority  of  cases,  al- 
though it  may  be  necessary  to  wait  until  there  has  been  a  discharge 
from  the  wound  for  three  or  four  days  before  they  can  be  found. 

The  wall  of  the  abscess  consists  of  Uver  substance  which  is  soft  and 


ABSCESS    OF   THE    LIVER  547 

irregular  and,  exhibits  masses  of  necrotic  liver  tissue.  Surrounding  the 
abscess  wall  may  be  found  areas  of  necrosis  which  usually  do  not  present 
signs  of  suppuration. 

Symptomatology. — The  symptoms  of  abscess  of  the  liver  vary 
with  the  nature  and  severity  of  the  preexisting  condition,  with  the 
pathway  of  infection,  and  with  the  nature  and  virulence  of  the  infect- 
ing micro-organism.  In  a  great  many  instances,  the  symptoms  are 
over-shadowed  by  those  of  a  coexisting  inflammatory  disease,  especially 
of  the  biUary  tract.  In  other  instances  the  abscess  is  latent,  giving  rise 
to  no  symptoms,  and  being  found  unexpectedly  at  autopsy. 

In  traumatic  abscess  there  usually  is  pain  in  the  liver  region  which  is 
markedly  increased  by  pressure.  Change  of  position  will  often  cause 
increase  in  pain.  If  the  abscess  be  located  in  the  upper  part  of  the  right 
lobe  pain  will  often  be  referred  to  the  shoulder.  A  palpable  friction  rub 
may  be  elicited  in  some  cases  where  perihepatitis  is  present.  If  there 
is  involvement  of,  or  pressure  upon,  the  biUary  ducts,  jaundice  will 
be  present.  The  Hver  usually  is  enlarged,  more  or  less  irregular  in 
outline,  and  a  fluctuating  mass  possibly  may  be  detected.  Chills, 
fever,  sweating,  and  a  high  leukocytosis  generally  are  present.  If  an 
external  wound  allows  the  discharge  of  pus,  hepatic  cells  will  be  found 
in  the  pus  or  in  the  scrapings. 

In  pyemic  (embolic)  abscess  the  symptoms  may  be  entirely  over- 
shadowed by  the  symptoms  of  the  primary  disorder.  As  a  rule  the 
hepatic  symptoms,  if  any  are  noticed,  develop  while  the  primary 
affection,  such  as  appendicitis,  is  still  active.  When  the  liver  compli- 
cation remains  latent  for  a  time,  as  sometimes  is  the  case  according  to 
Quenu  and  Mathieu  (191 1)  when  the  infection  follows  acute  appen- 
dicitis, the  symptoms  may  not  become  evident  until  weeks  after  the 
entire  disappearance  of  all  appendiceal  symptoms  (page  542).  In 
these  cases  the  general  condition  of  the  patient  may  not  be  satisfactory 
and  possibly  there  may  be  a  persistent  pallor  with  emaciation,  but  a 
comparatively  long  free  interval  will  elapse  before  the  symptoms  of 
acute  suppurative  hepatitis  assert  themselves.  In  such  cases  the 
course  resembles  that  seen  in  amebic  abscess.  In  the  usual  type  of 
case,  the  most  significant  local  symptoms  are  pain  in  the  hepatic 
region,  often  referred  to  the  right  shoulder,  and  tenderness  of  the  liver 
with  enlargement  of  that  organ.  The  general  symptoms  consist  of 
chills,  sweats,  fever  of  the  remittent  type,  perhaps  jaundice,  and  a 
marked  increase  in  the  leukocytes. 

Through  the  courtesy  of  Dr.  Homer  C.  Bloom,  with  whom  he 
was  associated,  the  senior  author  is  able  to  report  the  following  case: 


548  SURGERY    OF    THE    LIVER 

E.  B.,  fifty-three  years  of  age;  native  of  France;  had  had  frequent  attacks  of 
what  he  said  his  doctors  caUed  gall-stone  colic;  these  attacks  dated  back  ten  years; 
had  been  jaundiced  more  or  less  ever  since  the  first  attack;  drank  rather  heavily 
of  alcoholic  stimulants;  was  a  large  eater.  Had  been  losing  strength  and  flesh 
rapidly  during  the  past  year,  more  or  less  gastro-intestinal  disturbance,  marked 
constipation. 

April  22,  1905,  patient  suffering  severe  and  agonizing  pain  over  the  region  of  the 
gall-bladder;  there  was  marked  tenderness  over  this  region  as  well  as  over  the  upper 
part  of  the  abdomen  and  liver.  Jaundice  almost  bronze  in  color.  The  attack  had 
been  ushered  in  by  a  chiU.  There  was  marked  dullness  over  the  entire  right  side, 
extending  three  inches  below  the  lower  rib  and  as  high  as  the  right  nipple  and 
posteriorly  to  the  level  of  the  angle  of  the  scapula.  There  was  considerable  disten- 
tion of  the  abdomen  and  pronounced  rigidity  over  the  region  of  the  gall-bladder. 

Attacks  continued  at  longer  and  shorter  intervals  until  May  8,  when  operation 
was  performed. 

Operation. — Common  duct  distended  with  small  stones  and  debris;  common 
duct  opened  and  emptied,  but  immediately  from  the  liver  the  same  character 
of  material  escaped  in  large  amounts.  A  drainage  tube  was  put  in  the  common 
duct  and  the  same  material  with  bile  continued  to  drain  until  the  death  of  the 
patient. 

Autopsy  revealed  a  tremendous  liver  at  least  three  times  the  weight  of  a 
normal  liver;  all  through  the  structure  of  the  liver  were  minute  abscesses  and  in 
that  part  nearest  the  ducts  were  hundreds  of  biliary  stones  the  size  of  a  small  pea. 
The  kidneys  were  diseased,  the  right  side  of  the  heart  dilated  and  the  abdominal 
cavity  filled  with  bloody  fluid.     A  section  of  the  liver  is  shown  in  Plate  VII. 

In  amebic  {tropical)  abscess  the  symptoms,  in  3.^  per  cent,  of  the 
cases,  are  entirely  latent,  the  abscess  either  remaining  quiescent  or 
growing  so  insidiously  that  rupture  gives  rise  to  the  first  demonstrable 
symptoms  (Rouis).  Spontaneous  rupture  is  a  common  event  in 
large  abscesses,  Cyr  (1887)  having  found  a  rupture  in  159  cases  in 
a  series  of  563,  or  in  about  28  per  cent.  The  abscess  opened  into 
the  lungs  in  fifty-nine,  into  the  pleura  in  thirty-one,  into  the  peri- 
cardium in  one,  into  the  peritoneum  in  thirty-nine,  into  the  intestine 
in  thirteen,  into  the  stomach  in  eight,  into  the  kidney  in  two  cases. 
In  the  great  majority  of  all  cases  (nearly  60  per  cent.)  rupture  occurs 
through  the  diaphragm.  Flexner  (1897)  reported  two  instances  of 
rupture  into  the  inferior  vena  cava. 

The  onset  of  the  amebic  abscess  usually  is  slow.  The  patient 
for  months  may  complain  of  general  ill-health,  malaise  and  increasing 
weakness,  without  evincing  any  symptoms  that  refer  directly  to  the 
liver.  When  there  is  a  previous  histor}^  of  life  in  the  tropics,  of  dysen- 
tery or  other  marked  intestinal  disturbance,  these  general  symptoms 
become  significant  and  a  careful  examination  of  the  hepatic  region 
and  of  the  stools  should  be  made.     Pain  is  entirelv  absent  in  about 


Plate  VII 


03     »0 


< 


C 

O 


3 
a, 

0, 
3 
03 


ABSCESS    OF    THE    LIVER  549 

20  per  cent,  of  cases.  In  other  cases  there  will  be  a  dragging  sensation 
and  some  discomfort.  When  the  abscess  approaches  the  peritoneum, 
there  will  be  actual  pain,  at  times  sharp  and  stabbing.  The  pain 
seldom  is  referred  to  the  shoulder,  unless  the  abscess  is  near  the  surface, 
near  the  gall-bladder,  or  in  the  Spigelian  lobe.  The  temperature 
may  be  normal  or  of  a  severe  septic  type,  depending  upon  the  presence 
or  absence  of  pyogenic  bacteria  in  the  abscess.  In  the  purely  amebic 
cases,  there  is  very  slight  increase  of  leukocytes  with  a  corresponding 
increase  of  polynuclears.  Jaundice  will  not  be  present  unless  there 
is  pressure  on  the  larger  branches  of  the  hepatic  ducts. 

Diagnosis. — In  typical  cases  a  diagnosis  usually  is  not  difficult. 
In  other  cases,  either  because  the  symptoms  vary  so  greatly  from 
the  type,  or  because  they  are  absent,  a  diagnosis  may  be  very  difficult 
to  make.  A  provisional  diagnosis  should  be  made  from  the  history 
of  the  case,  the  general  appearance  of  the  patient,  and  the  clinical 
picture  presented.  If  the  patient's  physical  condition  is  not  very 
serious,  further  study  generally  will  make  the  diagnosis  clear.  Ex- 
ploration of  the  liver  with  a  trocar  never  should  be  practised  on  account 
of  the  great  danger  of  infecting  either  the  peritoneal  or  the  pleural 
avity.  If  exploration  is  necessary  to  establish  a  diagnosis,  an  in- 
Ciaion  should  be  made  of  sufficient  size  to  expose  the  liver  and  permit 
its  examination  by  the  fingers  and  the  exploring  needle  under  full 
control  of  vision. 

Skiagraphic  examination  is  of  value  in  showing  the  extent  of  the 
swelling  of  the  liver,  and  in  determining  its  upper  border.  It  is  of 
little  value  in  arriving  at  a  differential  diagnosis,  but  may  be  of  great 
aid  in  determining  the  size,  position,  and  mobility  of  the  liver. 

In  traumatic  abscess,  where  a  communication  leads  from  the  ex- 
terior to  the  abscess  cavity,  the  diagnosis  may  be  cleared  up  at  once 
by  finding  liver  cells  in  the  pus  being  discharged.  Where  there  is  no 
external  wound,  the  diagnosis  depends  on  the  history  of  traumatism 
followed  by  symptoms  which  point  to  a  lesion  of  the  liver  accompanied 
by  fever  of  a  septic  type,  chills,  etc. 

A  mistaken  diagnosis  may  be  made,  as  is  shown  in  the  following 
case. 

A.  M.,  male,  aged  forty-two  years,  admitted  to  the  German  Hospital  December 
3,  1912.  In  1803  the  patient  had  been  in  the  British  Army  in  Egypt  and  had  had 
a  severe  attack  of  dysentery.  During  the  four  years  he  remained  in  Egypt  he  had 
had  repeated  attacks  of  dysentery  and  lost  considerable  weight.  Since  leaving  Egypt, 
his  bowels  had  been  regular,  but  were  moderately  loose  at  times  although  there  was 
no  return  of  the  dysentery. 


550  SURGERY   OF    THE    LIVER 

Five  months  prior  to  admission  to  the  hospital,  he  was  kicked  in  the  abdomen 
by  a  horse  and  was  in  bed  from  the  effects  of  the  injury  five  weeks.  He  then  re- 
turned to  work  but  had  to  stop  and  return  to  bed.  \"omiting  began  soon  after  the 
reception  of  the  injury  and  has  been  more  or  less  persistent  ever  since.  He  has  lost 
ten  pounds  in  weight.  Has  not  been  jaundiced  at  any  time.  Two  days  before 
admission,  patient  had  a  severe  chill  which  lasted  for  two  hours. 

On  admission,  examination  revealed  a  mass  the  size  of  a  grape  fruit  centering  in 
the  gall-bladder  region,  somewhat  nodular  and  evidently  part  of  the  liver.  It 
extended  below  the  ribs  in  the  mid-costal  line.  The  mass  was  tender.  Abdomen 
otherwise  negative.     Diagnosis  of  liver  abscess  made. 

Operation,  December  7,  191 2. — Ether  anesthesia.  Incision  through  right 
rectus  muscle.  Examination  of  the  mass  proved  it  to  be  located  entirely  within 
the  gastro-hepatic  omentum,  the  liver  being  apparently  normal.  A  trocar  and 
canula  introduced  into  the  mass  and  a  considerable  quantity  of  dark  fluid  aspirated 
No  rupture  of  the  common  duct  detected.  Cavity  drained  and  wound  closed  to 
drainage.  Examination  of  the  aspirated  fluid  showed  it  to  be  blood,  and  free  from 
bile.     Patient  recovered,  and  left  the  hospital  January  13,  1913. 

In  pyemic  (embolic)  abscesses  the  diagnosis  cannot  be  made  readily 
if  the  symptoms  of  the  primary  disorder  are  at  all  prominent.  The 
general  sjonptoms  of  involvement  of  the  liver  during,  or  following, 
any  acute  infectious  disease  or  any  suppurative  process  should  make  the 
diagnosis  of  abscess  probable.  Usually  there  will  be  fever,  chills, 
sweats,  marked  increase  of  leukocytes,  and  sometimes  jaundice,  en- 
largement of  the  liver,  with  pain  and  tenderness  beneath  the  right 
costal  margin. 

In  amebic  [tropical)  abscess,  the  diagnosis  often  is  attended  by 
much  difficulty.  Here  the  past  history  is  most  important.  With  a 
history  of  dysentery  or  a  sojourn  in  tropical  climes  and  the  presence  of 
pain  in  the  region  of  the  liver,  often  referred  to  the  right  shoulder, 
tenderness  and  progressive  enlargement  of  the  Hver,  leukocytosis, 
especially  if  increased  in  the  evening,  fever,  chills  and  sweating,  the 
diagnosis  of  amebic  abscess  may  be  made.  The  fever  will  vary  from  a 
very  mild  to  a  moderate  or  a  severe  degree,  depending  upon  the  presence 
or  absence  of  pus-forming  micro-organisms.  When  the  amebic 
abscess  becomes  secondarily  infected  with  pyogenic  bacteria  the  symp- 
toms wiU  be  much  more  severe  than  in  the  simple  amebic  cases.  The 
leukocytes  will  vary  from  15,000  to  30,000,  part  of  which  increase  may 
be  due  to  the  intestinal  disease.  According  to  McDill  (1907),  colonic 
irrigations  and  saline  purgatives  will  eliminate  the  leukocytosis  due  to 
the  intestinal  infection.  One  of  the  best  indicators  of  the  presence  of 
pus  is  a  high  leukocyte  count  in  the  afternoon.  Examination  of  ordin- 
ary stools  may  be  negative.  McDill  claims,  however,  that  if  amebae 
are  present  they  always  will  be  found  in  the  third  or  fourth  watery  stool 


ABSCESS   OF   THE   LIVER  55 1 

following  the  administration  of  saline  purges.  It  must  be  remembered 
that  the  amebic  abscess  may  be  latent  and  may  remain  so  for  an  in- 
definite period.  Manson  states  that  "the  most  common  mistakes  in 
diagnosis  are:  (i)  Failure  to  recognize  the  presence  of  disease  of  any 
description,  even  when  an  enormous  abscess  may  occupy  the  liver. 
(2)  Misinterpretation  of  the  significance  and  nature  of  a  basic  pneu- 
monia, a  condition  so  often  accompanying  suppurative  hepatitis.  (3) 
Attributing  the  fever  symptomatic  of  liver  abscess  to  malaria.  (4) 
Mistaking  other  diseases  for  abscess  of  the  liver  and  vice  versa — for 
example,  hepatitis  of  a  non-suppurative  nature,  such  as  that  attending 
malarial  attacks;  suppurative  hepatitis  before  the  formation  of  abscess; 
syphiHtic  disease  of  the  liver — softening  gummata  which  are  often 
attended  with  fever  of  hectic  type ;  pylephlebitis ;  suppurating  hydatid ; 
gall-stone  and  inflammation  of  the  gall-bladder;  subphrenic  abscess; 
abscess  of  the  abdominal  or  thoracic  wall;  pleurisy;  encysted  empyema; 
pyelitis  of  the  right  kidney;  pernicious  anaemia;  leukocythaemia;  scurvy' 
and  other  similar  blood  diseases  associatd  with  enlargement  of  the 
liver;  ulcerative  endocarditis;  kala-azar;  Malta  fever;  trypanosomiasis. 
Any  of  these  may  be  attended  with  fever  of  hectic  t3^e,  increased  area 
of  hepatic  percussion  dullness,  and  pain  in  and  about  the  liver." 

In  malaria  the  spleen  is  proportionately  larger  than  the  Hver.  In 
cases  of  amebic  abscess  of  the  liver  the  spleen  is  not  enlarged.  If  the 
spleen  is  enlarged  in  a  case  of  hepatic  abscess,  this  probably  is  embolic 
in  origin.  The  fever  in  malaria  is  marked  during  the  day,  while  in 
liver  abscess  the  rise  of  temperature  is  seen  in  the  evening.  The  blood 
picture  in  malaria  is  quite  different  from  that  of  hepatic  abscess,  the 
former  showing  the  Plasmodium  which  is  absent  in  the  latter;  in  abscess 
there  usually  is  a  high  leukocyte  count  with  a  corresponding  increase 
of  the  polynuclear  cells,  which  is  not  seen  in  malaria.  The  administra- 
tion of  quinine  will  generally  clear  up  the  diagnosis  between  malaria 
and  liver  abscess. 

In  choleUthiasis  and  cholecystitis  and  in  chronic  calculous  obstruc- 
tion of  the  common  duct,  the  history  will  have  great  weight  in  making 
the  diagnosis.  In  these  conditions  the  symptoms  point  to  conditions 
of  the  biHary  tract  rather  than  to  the  liver  itself.  The  pyemic  abscess, 
complicating  acute  infection  of  the  bihary  tract,  cannot  always  be 
recognized,'  although  the  increased  area  of  tenderness  over  the  hepatic 
region  in  hver  abscess  might  cause  one  to  infer  that  the  liver  had  been 
infected. 

Prognosis. — The  prognosis  in  traumatic  abscess  will  depend  upon  the 
character  of  the  injuring  force,  the  portion  of  the  liver  involved,  and  the 


552  SURGERY    OF    THE    LIVER 

virulence  of  the  infecting  mico-organism.  The  prognosis  always  is 
grave. 

In  pyemic  abscess,  especially  when  multiple,  the  prognosis  always  is 
very  grave  and  according  to  some  writers,  hopeless.  Dieulafoy  stated 
(1900)  that  infection  of  the  liver  from  acute  appendicitis  is  always  fatal. 
His  statement  was  challenged  by  Quenu  and  Mathieu  (191 1)  who 
analyzed  fourteen  cases  which  they  claim  are  of  this  nature.  The 
infectious  focus  was  single,  or  there  were  only  few  foci,  and  operative 
measures  cured  twelve  of  the  fourteen  cases  (page  541).  When  the 
foci  are  multiple  the  condition  almost  always  results  fatally.  Person- 
ally, we  have  never  seen  recover}-  in  a  case  of  multiple  abscess  of  the 
liver  due  to.  acute  appendicitis. 

In  aviehic  abscess  death  may  occur  in  untreated  cases  from  sepsis 
following  perforation  into  the  peritoneal  cavity  with  peritonitis. 
Spontaneous  cure  may  result  if  the  rupture  occurs  into  the  pleural 
cavity  or  the  lung,  but  very  rarely  if  the  rupture  drains  the  abscess 
into  the  stomach  or  colon.  Early  operative  interference  always 
makes  the  prognosis  more  favorable.  Coffin  quotes  ]\Ianson  as  having 
found  a  mortality  of  57.7  per  cent,  in  the  Indian  Army  from  1891  to 
1S94.  Of  thirty-four  cases  analyzed  by  Coffin,  sixteen  died.  One 
patient  died  out  of  three  operated  upon  by  the  senior  author,  Herrick 
(1910)  lays  great  stress  on  the  differential  leukocyte  count,  in  making 
the  prognosis  of  these  cases.  He  found  that  when  the  polynuclear 
count  was  below  80  per  cent,  the  prognosis  was  good,  the  operative 
mortality  being  only  6.6  per  cent,  whereas  in  cases  where  the  poly- 
nuclear cells  were  over  80  per  cent,  the  operative  mortality  was  38  per 
cent. 

Treatment. — The  proper  treatment  of  liver  abscess  is  drainage.  As 
pointed  out  by  Herrick  "the  one  vital  necessity  is  that  the  abscess 
should  be  opened  at  its  point  of  election,  which  would  be  the  point 
where  the  abscess  approaches  nearest  to  the  surface  of  the  liver." 

Two  avenues  of  approach  are  open  to  the  surgeon:  one  through  the 
peritoneal  cavity,  and  the  other  the  transpleural  route.  The  "com- 
bined operation,"  similar  to  that  described  in  connection  with  injuries 
of  the  diaphragm  (page  285),  presents  no  advantages,  and  should  not  be 
employed.  Xo  attempt  should  be  made  to  localize  the  abscess  by  means 
of  the  aspirating  needle,  as  it  is  unreliable  and  fatalities  have  followed  its 
use.'  If  the  abscess  cannot  be  clearly  localized  by  the  physical  findings, 
an  exploratory  laparotomy  should  be  performed.     This  will  enable  the 

'  Puncture  of  the  liver  was  long  in  use  as  a  therapeutic  measure  under  the  name  of 
"hepatic  phlebotomy"  (Harley,  1886). 


CIRRHOSIS    OF    THE    LIVER  553 

surgeon  to  make  a  careful  examinalion  of  the  liver,  and  show  him  where 
the  incision  into  the  liver  should  be  made.  If  accessible  from  within 
the  abdominal  cavity,  the  abscess  may  now  be  opened,  after  isolating 
the  field  of  operation  by  gauze  packs.  In  most  cases,  however,  the 
approach  by  thoracotomy  is  to  be  preferred.  If  the  needle  is  used  for 
exploration  it  should  be  followed  by  immediate  operation,  before  with- 
drawing it,  whenever  pus  is  found.  However,  we  are  firmly  of  the 
opinion  that  it  is  dangerous  to  explore  before  sufficient  exposure  has 
been  obtained  by  a  free  incision.  If  the  abscess  cannot  be  located 
readily  after  the  abdomen  has  been  opened,  it  may  then  be  proper  to 
resort  to  puncture  of  the  liver  with  an  exploring  needle.  Under  such 
circumstances,  as  pointed  out  by  Terrier  and  Auvray  (1907),  this 
procedure  can  do  no  harm,  and  may  do  good,  by  relieving  the  hepatic 
congestion  by  means  of  what  Harley  (1886)  called  hepatic  phlebotomy. 
The  transpleural  route,  employed  in  1885  by  Knowsley  Thornton, 
gives  the  best  access  to  the  greatest  area  and  should  always  be  used 
unless  the  abscess  presents  anteriorly,  or  unless  laparotomy  is  indicated 
for  diagnostic  purposes.  (For  description  of  operation  see  Chapter 
XXIV).  The  transpleural  route  was  employed  by  Israel,  as  early  as 
1879,  in  a  case  of  hydatid  cyst  of  the  liver  (page  567). 

Cirrhosis  of  the  Liver 

Two  main  types  of  cirrhosis  of  the  liver  are  recognized,  portal  and 
biliary.  Kelly  (1908)  used  these  terms,  with  subtypes,  because  in  one 
the  etiological  factor  is  "perhaps  always  transmitted  by  the  portal 
circulation,  the  new-formed  connective  tissue  is  especially  conspicuous 
in  and  about  the  portal  spaces  in  the  liver,  and  the  obtrusive  symptoms 
are  those  of  portal  obstruction."  The  other  is  called  biliary  cirrhosis 
because  the  essential  lesion  is  a  radicular  cholangeitis  and  the  conspicu- 
ous clinical  feature  is  jaundice,  due  to  obstruction  to  the  free  flow  of 
bile. 

In  portal  cirrhosis  the  obtrusive  sjonptoms  are  ascites  and  gastro- 
intestinal hemorrhages,  the  latter  being  the  result  of  varices  in  the 
ultimate  branches  of  the  portal  system  of  veins.  It  was  maintained  by 
Hale  White,  RoUeston,  and  others  and  Kelly  concurred  in  this  view, 
that  patients  with  uncomplicated  portal  cirrhosis  of  the  liver  do  not 
long  survive  the  onset  of  ascites,  rarely  living  long  enough  for  more 
than  one  tapping  to  be  necessary.  These  authorities  claim  that  in 
patients  who  live  and  are  tapped  many  times,  either  the  diagnosis  of 
portal  cirrhosis  is  incorrect,  or  the  condition  is  complicated  by  peri- 


554  SURGERY   OF   THE    LIVER 

hepatitis,  chronic  peritonitis,  etc.     It  is  only  in  this  latter  class  of 
patients  that  the  question  of  surgical  treatment  arises. 

In  cases  of  biliary  cirrhosis  there  sometimes  are  accompanying 
lesions  of  the  gall-bladder  and  bile-ducts,  which  may  call  for  surgical 
treatment.  A  distinction  was  drawn  by  Kelly  between  true  biliary 
cirrhosis  so  complicated,  and  cases  of  obstructive  jaundice  with  chronic 
intrahepatic  pericholangeitis,  resulting  in  disseminated  cirrhosis  of  the 
liver.  But  W.  J.  Mayo  (1918)  states  that  he  has  never  seen  a  case  of 
biliary  cirrhosis  which  could  be  considered  such  as  used  to  be  known 
by  the  name  of  Hanot  (1895)  and  he  is  of  the  opinion  that  such  a  disease 
probably  does  not  exist.  The  large  majority  of  cases  periously  so- 
called  he  classes  as  instances  either  of  hemolytic  icterus  or  the  ordinarj- 
type  of  biliary  cirrhosis;  the  former  is  primarily  a  splenic  disease  with 
a  work  hypertrophy  of  the  liver,  but  as  in  60  per  cent,  of  the  cases  in 
which  he  has  removed  the  spleen  for  this  disease  there  were  also  present 
gall-stones  with  recurring  exacerbations  of  infection,  the  confusion  is 
not  hard  to  understand.  Eppinger  and  Ranzi,  as  long  ago  as  1914, 
stated  that  in  all  cases  of  "hypertrophic  cirrhosis"  with  jaundice  and 
enlarged  spleen,  but  with  no  alcoholic  historj^,  splenectomy  must  be 
considered.  They  had  done  10  splenectomies  in  this  class  of  cases, 
with  2  deaths;  one  patient  was  not  traced,  but  seven  remained  in  good 
health  at  periods  varj'ing  from  4  months  to  2  years  after  operation. 
Surgical  treatment  in  cases  of  portal  cirrhosis  of  the  Hver  had,  until 
recently,  for  its  object  the  relief  of  ascites,  or  of  recurring  hemorrhages, 
and  not  the  cure  of  the  lesion  in  the  liver.  The  operations  formerly 
advocated,  therefore,  must  be  considered  as  measures  taken  for  the 
relief  of  s>-mptoms  and  not  as  therapeutic  measures  inaugurated  to  cure 
the  underlying  disease.  Little  can  be  expected  from  operative  treat- 
ment of  cases  of  obstructive  jaundice  if  this  is  postponed  until  hepatic 
cirrhosis  has  developed.  Surgical  treatment  of  hepatic  cirrhosis  therefore 
is  confined  almost  exclusively  to  relief  of  the  ascites  or  hemorrhages  which 
accompany  the  portal  form  of  the  disease. 

Etiological  Factors.^ — It  usually  has  been  taught,  on  the  author- 
ity of  Rolleston,  that  ascites  in  cases  of  cirrhosis  of  the  liver  is  due  to 
portal  pressure  and  to  toxemia,  the  former  causing  conditions  favorable 
to  peritoneal  effusion,  add  the  latter  interfering  with  the  normal  activity 
of  the  endothelial  cells  of  the  peritoneum.  Portal  obstruction  alone  is 
not  the  chief  factor  in  the  production  of  ascites,  because  the  radicles  of 
the  portal  vein  lie  nearer  the  mucous  than  the  serous  surfaces  of  the 
gastro-intestinal  tract  and  dilatation  of  these  radicles  results  in  the 
production  of  varicosities;  and  these  varicosities  manifest  their  pres- 


CIRRHOSIS   OF   THE   LIVER  555 

ence  not  by  the  occurrence  of  ascites,  but  by  hemorrhages.  Ascites 
is  caused  almost  solely  by  changes  in  the  endothelium  composing  the 
peritoneum ;  it  is  in  the  nature  of  a  chronic  serositis.  In  other  words 
the  toxemia  due  to  disordered  hepatic  function  is  a  much  more  impor- 
tant cause  of  ascites  than  is  the  existence  of  portal  obstruction.  But 
cases  of  portal  cirrhosis  sometimes  are  complicated  by  tuberculosis  of  the 
peritoneum,  or  by  a  chronic  polyserositis  associated  ivith  cardiac  disease; 
and  in  such  cases  it  may  not  be  the  hepatic  toxemia  but  the  compHca- 
ting  disease,  which  is  responsible  for  the  peritoneal  effusion. 

Under  normal  conditions  the  various  anastomoses  between  the 
portal  and  systemic  venous  channels  are  able  to  care  for  the  sUght 
obstruction  of  the  portal  system.  As  stated  by  Deaver,  "the  radicles 
of  the  portal  vein  anastomose  with  the  systemic  veins  in  numerous 
places;  among  these  anastomoses  are  the  following:  Radicles  of  the 
superior  hemorrhoidal  vein  anastomose  with  branches  of  the  middle 
and  inferior  hemorrhoidal  veins,  these  last  being  tributaries  of  the  inter- 
nal iliac  vein ;  the  gastric  tributaries  of  the  portal  vein  anastomose  with 
the  lower  esophageal  veins,  which  empty  into  the  azygos  vein.  In  the 
suspensory  ligament  of  the  liver  are  veins  which  connect  the  portal 
system  with  the  veins  of  the  diaphragm;  along  the  round  ligament  of 
the  liver  there  are  one  or  two  veins  which  effect  an  anastomosis  between 
the  portal  system  and  the  veins  of  the  abdominal  wall." 

When  there  is  obstruction  of  the  portal  system,  as  is  seen  in  cirrhosis 
of  the  liver,  these  anastomosing  channels  become  enlarged  to  assist 
in  estabhshing  collateral  circulation.  The  enlargement  of  the  spleen, 
so  frequently  seen  in  connection  with  cirrhosis  of  the  liver,  is  due  to  the 
damming  back  of  the  blood  in  the  splenic  vein  as  a  result  of  the  inter- 
ference with  the  portal  circulation.  If  the  obstruction  of  the  portal 
system  cannot  be  cared  for  by  the  enlarged  venous  anastomoses, 
leakage  occurs  with  repeated  hemorrhages  from  the  gastro-intestinal 
tract. 

Most  of  the  operative  methods  proposed  for  the  treatment  of  ascites 
with  cirrhosis  of  the  liver  seem  to  have  been  based  on  the  theory  that 
the  ascites  occurred  as  a  direct  transudate  from  the  obstructed  portal 
system.  Many  of  the  methods  therefore  are  irrational,  and  if  successful 
the  happy  issues  have  been  due  to  factors  not  recognized  at  the  time  as 
essential.  Vidal  has  well  pointed  out  that  efforts  to  relieve  the  ascites 
by  attempts  to  establish  a  collateral  circulation  between  the  portal  and 
systemic  circulations  are  based  on  an  erroneous  idea  of  the  pathogenesis 
of  ascites.  The  quickest  and  surest  way  to  establish  such  a  collat- 
eral circulation  is  to  make  an  anastomosis  between  the  portal  vein  and 


03 


6  SURGERY    OF    THE    LWER 


the  vena  cava  (Eck's  fistula)  thus  draining  the  portal  blood  directly 
into  the  right  heart.  This  delicate  operation  was  successfully  per- 
formed by  Vidal  (1903);  he  was  forced  to  adopt  it  because  he  found 
there  was  no  omentum  available  for  epiplopexy,  and  as  the  patient  was 
nearly  exsanguinated  from  repeated  hemorrhages,  some  method  of 
relieving  the  portal  congestion  seemed  imperative;  but,  though  the 
hemorrhages  were  cured  the  Eck  fistula  did  not  prevent  the  recurrence 
of  ascites,  six  weeks  before  death,  which  occurred  four  months  after 
operation,  and  was  due  to  an  acute  general  infection  evidently  entero- 
genous. The  liver,  interposed  as  a  filter  to  the  hordes  of  microbes 
constantly  absorbed  by  the  portal  blood  stream,  was  side-tracked  by  the 
operation  and  these  bacteria  entered  the  general  circulation  with  un- 
diminished virulence,  so  that  death  from  acute  general  infection  must 
always  be  anticipated  under  such  circumstances.  Another  reason  for 
condemning  the  operation,  emphasized  by  Vidal,  is  that  the  with- 
drawal of  the  functions  of  the  liver  from  the  digestive  and  meta- 
bolic processes,  necessitates  an  almost  impossible  restriction  of  diet. 

The  various  methods  of  operative  treatment  proposed  for  cirrhosis 
of  the  liver  have  been  summarized  by  Ricketts  (1909),  as  follows: 

1.  Incision  through  the  abdomijial  wall,  with  temporary  or  perma- 
nent drainage  of  the  ascitic  fluid.  A  number  of  cases  have  been  per- 
manently benefitted  bj^  this  procedure. 

2.  Paracentesis,  or  puncture  through  the  abdominal  wall,  with 
temporary  or  permanent  drainage.  A  number  of  recoveries  have 
been  reported,  usually  after  a  number  of  tappings.  Lecreuz  reported, 
in  1902,  the  history  of  a  patient  from  whom  he  removed,  during  a 
period  of  five  years,  1750  liters  of  fluid  by  sixty-five  punctures;  the 
patient  remained  well  two  years  after  the  last  tapping.  The  pro- 
cedure, however,  usually  is  useless  except  for  temporary  relief  of  the 
distress  resulting  from  the  pressure  of  the  ascitic  fluid. 

3.  Hepatotomy,  or  incising  the  liver  to  various  depths  after 
having  first  opened  the  abdomen,  with  temjjorary  or  permanent 
drainage. 

4.  Hepatotomy  with  a  trocar,  followed  by  temporary'  or  permanent 
drainage.  The  results  obtained  are  about  the  same  as  with  hepato- 
tomy with  the  knife. 

5.  Cholangeiostomy.  Thornton  in  1887  .succeeded  in  draining 
the  biliary  tract  by  penetrating  the  right  lobe  of  the  li\-cr  to  one  of  the 
larger  branches  of  the  hepatic  duct,  in  which  calculi  were  lodged. 

6.  Cholccystenterostomy  has  been  performed  by  Combenale 
and  Dubar  for  the  purpose  of  eftecting  better  drainage. 


CIRRHOSIS    OF    THE    LIVER  557 

7.  Cholecystostomy  was  performed  by  Delageniere  in  1901  for 
cirrhosis  and  this  method  of  treatment  was  fully  discussed  by  his 
pupil  Bernard. 

8.  Injection  of  caustics  into  the  peritoneal  cavity  has  been  resorted 
to  on  the  theory  that  the  irritation  produced  will  cause  increase  in  the 
activity  of  the  peritoneum. 

9.  Ligation  of  the  portal  vein  has  been  performed  for  the  pur- 
pose of  lessening  the  congestion  of  the  liver  and  encouraging  the 
establishment  of  a  collateral  circulation.  The  procedure  was  described 
by  Pascale  in  1901. 

10.  Hepatopexy  (page  539)  was  performed  by  Delageniere  in 
1897.  Ricketts  reports  two  of  his  own  cases  of  cirrhosis  in  which  the 
same  operation  was  performed. 

11.  Epiplopexy  or  omentopexy,  variously  described  as  the  Talma, 
the  Talma-Drummond,  or  the  Morison  operation,  has  been  employed 
of tener  than  any  procedure  devised  (see  below) . 

12.  Eck's  fistula,  which  is  made  by  establishing  a  communica- 
tion between  the  portal  vein  and  the  vena  cava.  Vidal's  (1903) 
operation  of  this  nature  has  already  been  discussed. 

13.  Splenopexy,  or  anchoring  the  spleen  to  the  anterior  peri- 
toneal wall,  with  or  without  omentopexy,  has  given  some  very  favorable 
results. 

14.  Multiple  visceropexy  is  suggested  by  Ricketts  as  a  procedure 
that  might  accomplish  much  good. 

15.  Splenectomy  has  been  employed  by  Mayo  (1918)  and  others, 
on  the  theory  that  the  hepatic  cirrhosis  might  be  secondary  to  metabolic 
poisons  derived  from  a  diseased  spleen.  Mayo  suggests,  however,  that 
removal  of  the  spleen  diverts  all  the  blood  from  the  general  circula- 
tion which  would  normally  reach  the  liver  by  way  of  the  splenic  vein, 
and  thus  relieves  the  subnormal  Hver  of  an  overload.  And  he  reports 
that  of  five  patients  with  portal  cirrhosis  treated  by  splenectomy  four 
recovered  and  were  markedly  improved.  But  the  query  propounded 
by  J.  Bapst  Blake  (1918),  when  this  subject  was  under  discussion  by  the 
American  Surgical  Association,  remains  unanswered:  Does  removal 
of  the  spleen  diminish  the  hepatic  circulation? 

We  believe  that  in  seeking  operative  relief  for  the  symptoms  of 
portal  cirrhosis,  the  surgeon  always  should  bear  in  mind  what  the 
two  chief  symptoms  are — ascites  and  hemorrhages;  and  that  remember- 
ing the  probable  pathogenesis  of  each  of  these  symptoms  he  should 
adopt  his  plan  of  operation  accordingily.  If  the  hemorrhages  are  the 
predominant  feature,  measures  for  establishing  a  collateral  circula- 


5S8  SURGERY    OF    THE    LIVER 

tion  are  indicated;  if  there  are  no  hemorrhages,  but  ascites  is  annoy- 
ing, it  is  probable  that  complete  evacuation  of  the  fluid  by  laparotomy, 
with  such  alteration  in  the  nutrition  of  the  serous  surfaces  of  the  perito- 
neum as  accompanies  this  simple  operation,  will  be  as  effective  in 
relieving  the  ascites  as  will  any  more  complicated  procedure.  We 
quite  agree  with  Bogojawlensky  (1909)  who  claimed  that  the  benefit 
of  the  operation  of  omentopexy  is  due  to  the  laparotomy  and  consequent 
hyperemia  rather  than  to  the  fixation  of  the  omentum,  although  the 
latter  may  help.  He  induces  as  much  h}-peremia  as  possible  during  the 
operation.  Bogojawlensky  also  claims  that  it  is  essential  that  all 
ascitic  fluid  be  removed  from  the  peritoneal  cavity  on  account  of 
the  danger  of  too  rapid  absorption  if  the  kidneys  are  not  functionating 
properly.  Dock  (1910)  also  is  of  the  opinion  that  the  relief  of  the 
ascites  may  be  due  mor6  to  the  operation  on  the  serous  membrane 
than  to  the  opening  of  collateral  circulation. 

The  most  efficient  method  for  the  establishment  of  a  collateral 
circulation  is  epiplopexy  (omentopexy).  Talma  began  his  studies  on 
this  subject  in  1S89;  but  the  first  case  in  which  the  operation  was 
successful  was  pubKshed  by  Drummond  and  Morison  in  1896.  We 
do  not  believe  that  this  operation  is  indicated  in  cases  of  cirrhosis 
unaccompained  by  gastro-intestinal  hemorrhages;  and  when  its  per- 
formance has  been  followed  by  the  disappearance  of  an  uncom- 
plicated ascites,  it  is  highly  probable,  as  noted  above,  the  success  was 
attributable  to  other  factors  in  the  operation  and  not  to  the  epiplopexy 
itself. 

Complication  of  cirrhosis  with  nephritis  does  not  necessarily 
contraindicate  Talma's  operation;  but  any  operation  is  contrain- 
dicated  when  the  patient  is  markedlj'  weakened  by  disease  of  the 
heart  and  kidneys;  and  is  absolutely  contraindicated  when  the  func- 
tional activity  of  the  liver  cells  has  been  abohshed,  as  showm  by  the  pres- 
ence of  urobilinuria  and  acholia.  Long-continued  jaundice  acts  as  a 
contraindication  on  account  of  the  predisposition  in  these  cases  to 
postoperative  hemorrhage. 

The  results  of  the  operation  of  epiplopexy,  undertaken  for  the 
relief  of  ascites  in  cirrhosis  of  the  b'ver  may  be  seen  from  the  figures 
collected  by  Ricketts:  he  notes  1565  cases  in  which  the  operation  of 
epiplopexy  was  performed,  the  results  being  as  follows: 

Patients  cured 30 . 4  per  cent. 

Patients  relieved 19.8  per  cent. 

Patients  unrelieved 39-2  per  cent. 

Patients  died 10.6  per  cent. 


CIRRHOSIS    OF    THE    LIVER  559 

McWilliams  (1907)  quoted  the  following  statistics: 

Author  Cases  Symptomatic  Relief 

Koslowsky i68  46  per  cent. 

Greenough 105  42  per  cent. 

Monprofit 224  35  per  cent. 

Bunge  reports  33  per  cent,  of  permanent  cures  and  33  per  cent, 
improved. 

The  report  of  Dock  illustrates  the  usual  course  of  those  cases 
which  are  ultimately  cured  of  the  ascites.  In  this  case  tapping 
was  resorted  to  fourteen  times  and  was  followed  by  omentopexy, 
performed  in  1902  by  Edward  Hamilton  of  Houston,  Texas;  during 
the  following  seven  months  paracentesis  was  performed  ten  times  for 
the  relief  of  the  ascites.  These  tappings  were  followed  by  permanent 
relief,  internal  medication  fully  controlling  any  slight  subsequent 
recurrence  of  the  ascitic  fluid  during  the  seven  years  which  had  elapsed 
since  operation  up  to  the  time  of  Dock's  report  in  1909. 

The  technique  of  the  operation  is  discussed  in  Chapter  XXIV. 

For  the  relief  of  the  ascites,  as  already  pointed  out,  it  is  more 
rational  to  resort  to  laparotomy,  with  sponging  of  the  parietal  peri- 
toneum and  of  that  covering  the  liver;  or  even  a  resort  to  hepatopexy 
as  practised  by  Delageniere.  The  performance  of  epiplopexy  at  the 
same  time  is  not  to  be  condemned,  since  it  may  be  of  benefit  in  relieving 
unrecognized  gastro-intestinal  varices. 

Finally  removal  of  the  spleen  must  now  be  given  due  consideration 
in  cases  of  portal  as  well  as  in  those  of  biliary  cirrhosis;  for  even  though 
the  modus  operandi  of  this  method  of  treatment  remains  in  doubt,  there 
can  be  no  doubt  that  in  selected  cases  it  has  proved  its  value. 

Cysts  of  the  Liver 

The  most  common  cyst  of  the  liver  is  the  hydatid  or  echinococcus. 
Though  knowledge  of  hepatic  cysts  dates  back  to  the  times  of 
Hippocrates  and  Galen,  and  though  the  anatomists  of  the  sixteenth 
and  seventeenth  centuries  accurately  described  such  cysts,  in  those 
times  the  cysts  were  supposed  to  be  enlargements  of  the  lymphatics. 
Pallas  (1760)  proved  that  the  cysts  were  independent  parasites,  and 
also  showed  the  close  relation  they  held  to  the  tape-worm.  Bremser, 
in  1819,  pubhshed  the  first  accurate  account  of  the  echinococcus 
occurring  in  the  human  liver.  The  subject  was  thoroughly  discussed 
by  Davaine  in  his  treatise  on  intestinal  parasites,  first  published 
in  i860. 


560  SURGERY    OF    THE    LWER 

The  exciting  cause  of  the  echinococcus  cyst  is  the  Tcenia  echino- 
cocciis  (Echinococcus  granulosus),  a  parasite  found  in  the  upper  in- 
testinal tract  of  several  animals,  such  as  the  dog,  the  wolf,  and  the 
jackal.  Richardson,  in  1867,  and  later  Madelung  (1885)  have 
shown  that  the  echinococcus  is  also  found  in  sheep.  Kehr  (1904) 
states  that  the  domestic  cat  and  rabbit  may  also  be  the  source  of 
infection. 

The  ova  enter  the  gastro-intestinal  tract  of  man  with  food  or 
drink,  or  possibly  as  the  result  of  handling  or  being  licked  by  an  animal 
infested  by  the  parasite.  The  capsule  is  digested  in  the  intestinal 
tract,  and  the  embryo  is  liberated.  In  the  larval  state  the  echino- 
coccus is  globular  in  form.  It  possesses  six  booklets  and  four  suction 
discs  which  aid  it  in  boring  into  the  tissues.  It  finds  permanent 
lodgment  in  various  portions  of  the  body;  in  the  liver,  spleen,  kidney, 
lungs,  etc.,  the  liver  being  the  most  frequent  site  of  its  lodgment 
and  development.  It  is  probable  that  the  larvae  enter  the  radicles 
of  the  portal  vein  and  are  then  carried  directly  to  the  liver.  Some 
may  also  reach  the  liver  through  the  bile-ducts.  Douglas  (1909) 
quotes  Davaine  as  having  found  the  echinococcus  in  the  liver  in  166  of 
376  cases;  Bocker,  in  27  of  40  cases;  and  Weisser  in  451  of  900  cases. 
The  ova  as  a  rule  do  not  escape  again  from  the  human  body,  though 
they  are  discharged  constantly  from  the  bodies  of  sheep  in  the  slaughter 
house,  to  be  devoured  by  dogs  and  again  developed  into  tape-worm 
(Morris).  The  proper  means  of  prophylaxis  of  hydatid  disease  are  thus 
indicated,  in  guarding  the  food  supply  of  dogs,  and  in  proper  attention 
to  their  dejecta. 

Age  and  Sex. — Echinococcus  disease  is  seen  most  frequently  in 
those  between  the  ages  of  twenty  and  thirty  years.  It  may  be  found 
at  any  age;  even  in  the  fetus  the  cj^st  has  been  found  of  such  size  as 
to  prevent  delivery.     It  has  no  predilection  for  either  sex. 

Distribution. — Echinococcus  disease  is  found  most  frequently  in 
Iceland.  In  that  country  the  close  association  of  mankind'  with  dogs 
is  marked,  and  this  fact  is  held  accountable  for  its  frequency.  Accord- 
ing to  Morris  (1888)  one-seventh  of  the  human  mortality  in  Iceland 
was  due  to  hydatids.  The  multi-locular  cyst  rarely  is  seen  in  Iceland. 
In  Australia  and  Ital)-  the  disease  is  not  uncommon.  France  and 
Germany  are  rather  free  from  it,  while  in  England  and  the  United 
States  it  is  comparatively  rare. 

Pathology. — After  the  parasite  (in  larval  state)  reaches  the  liver 
it  loses  its  booklets  and  enters  the  immature  or  cysticercus  stage. 
Inflammatory  changes  cause  a  protective  connective-tissue  encapsula- 


ECHINOCOCCUS    CYSTS  56 I 

tion.  The  cyst-wall  consists  of  hco  layers,  an  outer  laminated  mem- 
brane or  capsule;  and  an  inner  vascular  layer  variously  designated 
as  the  parenchymatous,  granular,  or  germinal  layer.  The  contents 
consist  of  a  clear,  colorless,  transparent  fluid,  non-albuminous,  of  a 
specific  gravity  of  from  looo  to  1015.  It  contains  sodium  chloride 
and  traces  of  succinic  acid  and  of  sugar.  When  the  capsule  is  broken 
down  either  by  erosion  or  suppuration,  or  when  the  cyst  becomes 
infected  with  pyogenic  bacteria,  the  fluid  becomes  turbid;  and  some- 
times it  is  bloody  or  bile-stained.  Boinet  in  studying  hydatid  fluid 
extracted  a  ptomain  from  it  in  the  form  of  a  prismatic  crystal,  fern- 
leaf  in  shape.  The  death  of  a  mouse  occurred  five  minutes  after  the 
administration  of  three-sixty-fourths  of  a  grain  under  the  skin.  A 
larger  dose  given  to  a  rabbit  caused  convulsions,  alteration  in  the  rhythm 
and  rapidity  of  the  respirations,  tachycardia,  dilated  pupils  and 
collapse,  the  symptoms  usually  assigned  to  hydatid  intoxication. 
Fowler  states  that  this  toxin  is  much  more  abundant  in  cases  in  which 
puncture  and  electrolysis  have  transformed  the  clear  fluid  into  a 
turbid  syrupy  fluid  which  is  rich  in  albuminoid  matter. 

When  the  cyst  is  fertile,  daughter  cysts  develop  within  the  original 
or  parent,  cyst;  other,  or  granddaughter  cysts,  at  times  develop  within 
the  daughter  cysts.  The  heads  or  scolices  of  the  parasites  are  found 
on  the  inner  surface  of  the  germinal  layer,  in  pedunculated  vesicles 
called  "Brood-capsules."  The  walls  of  these  vesicles  are  similar  to 
those  of  the  primary  cyst.  A  single  scolex  or  several  scolices  may 
be  found  in  each  of  the  brood-capsules.  They  are  like  the  parent 
parasite,  having  the  same  number  of  booklets  and  suction  discs.  The 
scolex  may  be  free  in  the  capsule;  if  the  capsule  ruptures,  the  scolex 
will  then  be  found  free  in  the  cyst.  In  some  instances  deposits  of 
lime  salts  will  be  found  in  the  scolex. 

After  the  cysts  have  undergone  degenerative  changes,  the  booklets 
and  portions  of  the  cyst  membrane  may  be  found  in  the  resulting 
detritus.  Where  calcification  has  taken  place,  it  often  will  be  diflicult 
to  recognize  or  determine  the  causes  or  origin  of  the  cyst. 

Prudden  (191 1)  cites  two  rare  forms  of  echinococcus  cysts,  in  one 
of  which,  echinococcus  scolecipariens,  the  secondary  vesicles  are  formed 
on  the  outside  of  the  primary  cyst-wall.  The  second  variety,  echino- 
coccus muUilocularis,  which  is  more  common  in  man  than  the  former, 
results  from  disturbances  in  the  development  of  the  cysts.  In  an 
encapsulated  mass,  series  of  irregular  cysts  will  be  surrounded  by 
bands  of  connective  tissue  of  varying  widths.  This  has  been  called 
by  Vierordt  "echinococcus  alveolaris."     A  cross-section  of  the  tumor 

36 


562  SURGERY    OF    THE    LIVER 

gives  an  appearance  which  accounts  for  the  term  "alveolar  colloid" 
which  was  formerly  applied  to  it. 

Thompson  (1896)  exhibited  an"  interesting  specimen  of  multiple 
hydatids.  "The  Uver  was  the  seat  of  extensive  growths,  there  being 
five  distinct  tumors  in  various  stages  of  activity.  Two  had  sup- 
purated, two  had  died  and  had  been  converted  into  inert  masses, 
while  the  fifth  was  in  the  active  growing  stage."  Multiple  cysts 
occur  in  about  12.5  per  cent,  of  cases.  Their  existence  may  be  sus- 
pected at  operation  if  evacuation  of  the  first  cyst  does  not  cause  a 
sufficient  diminution  in  the  size  of  the  fiver. 

Echinococcus  cysts  of  the  liver  generaUy  form  in  the  right  lobe, 
and  in  about  90  per  cent,  of  the  cases  the  cyst  is  solitary.  Any  part 
of  the  liver  may  be  involved.  The  size  and  shape  of  the  organ  vary 
with  the  position  of  the  cyst.  If  it  is  in  the  centre  of  the  liver  there 
generally  is  a  more  or  less  uniform  enlargement;  if  near  the  border 
or  on  the  lower  surface  of  the  liver,  or  if  there  are  multiple  cysts, 
the  shape  of  the  liver  is  greatly  altered.  Cysts  on  the  lower  surface 
generally  grow  downward  and  ultimately  may  fill  the  greater  part 
of  the  abdomen,  even  reaching  the  peK-is,  as  in  a  case  reported  by 
R.  S.  Fowler  (1906).  When  growing  on  the  upper  surface  of  the  liver, 
the  pressure  agairist  the  diaphragm  may  be  great  enough  to  compress 
the  overl3dng  lung.  Usually  a  tumor  is  noticed  in  the  right  hypo- 
chondrium  or  in  the  epigastrium. 

Echinococcus  disease  may  last  for  j^ears.  The  growth  of  the 
cyst  is  slow,  the  course  of  the  disease  extending  over  a  period  of  from 
two  to  thirty  years.  It  may  exist  for  years  without  giving  rise  to 
symptoms  and  may  be  discovered  or  suspected  only  after  the  abdomen 
has  been  opened  at  autopsy.  In  an  analysis  of  twenty  cases,  Barrier, 
(1840)  found  that  in  three  the  disease  had  lasted  two  years;  in  eight, 
from  two  to  four  years;  in  four,  from  four  to  six  years;  and  in  the  re- 
maining fifteen  cases  the  duration  was  fifteen,  eighteen,  twenty  and 
even  thirty  years.  In  fourteen  cases  studied  by  Henry  Morris  (1888), 
the  average  duration  of  symptoms  was  about  seven  years.  In  the 
series  of  cases  studied  by  Cauchoix  (1908),  the  probable  duration  of  the 
disease  before  treatment  was  sought  is  indicated  in  fifteen  instances: 
this  period  Aaried  from  a  few  days  to  thirty-six  years  (Obs.  xxxvi). 
the  average  duration  of  s\Tnptoms  being  more  than  five  years. 

The  untreated  hydatid  may  progress  indefinitely,  death  from  another 
cause  intervening.  Death  may  result  at  any  time  from  rupture  as 
a  result  of  trauma,  or  from  infection  with  suppuration;  or  spontaneous 
rupture  without  infection  may  occur.     In  cases  where  the  parasite 


ECHINOCOCCUS   CYSTS  563 

dies,  or  ceases  to  grow,  the  cyst  usually  atrophies,  and  the  contents 
of  the  sac  resemble  sebaceous  matter,  or  are  greatly  altered  by  calca- 
reous changes.  A  spontaneous  cure,  of  course,  results.  If  the  cyst 
opens  into  the  biliary  apparatus,  sterile  bile  as  a  rule  will  kill  the  parasite 
and  effect  a  cure.  If  the  bile  is  infected,  however,  suppuration  of  the 
cyst  will  ensue.  The  cyst  may  rupture  spontaneously  into  one  of  the 
hollow  viscera,  such  as  the  stomach  or  intestine,  into  the  lung  or  pleural 
cavity,  or  into  the  free  peritoneal  cavity.  When  the  stomach  is  invaded 
the  contents  of  the  cyst  will  be  vomited ;  if  the  lung  is  the  organ  involved 
violent  coughing  will  cause  the  expulsion  of  the  fluid,  and  sometimes 
of  unbroken  daughter  cysts;  if  rupture  has  taken  place  into  the  intes- 
tine, the  contents  of  the  cyst  may  be  recovered  in  the  stools.  When 
rupture  takes  place  into  the  general  peritoneal  cavity,  the  result  will 
depend  upon  the  condition  of  the  cyst  contents:  if  there  is  infection 
present,  a  suppurative  peritonitis  will  follow  with  a  mortality  of  about 
90  per  cent. ;  if  the  contents  are  sterile,  multiple  cysts  may  form  in  the 
the  peritoneum,  unless  the  patient  succumbs  to  the  septic  condition 
caused  by  the  absorption  of  the  ptomains  and  toxins  contained  in  the 
fluid.  A  diagnostic  point  of  some  value  in  these  cases  is  the  urti- 
carial rash  which  develops  rather  rapidly.  Rupture  of  the  cyst  may 
be  external  in  rare  cases;  occasionally  it  ruptures  both  Liaternally  and 
externally.  Deve  (1907)  describes  hydatid  gaseous  cysts  [Pneumo- 
kystes  hydatiques)  of  the  liver,  a  condition  first  mentioned  byLaennec; 
the  condition  is  attributed  to  rupture  of  the  echinococcus  cyst  into  the 
stomach,  intestine  or  lung;  rarely  it  is  caused  by  putrefactive  changes 
within  an  unruptured  cyst.  The  term  is  also  applied  to  an  hydatid 
cyst  to  which  air  has  been  admitted  as  the  result  of  operative  pro- 
cedures, thus  being  analogous  to  the  term  "open  pneumothorax." 
Deve  collected  fifty-one  cases  of  hydatid  pneumocysts;  operation  was 
done  in  fourteen  cases  with  eight  deaths  resulting. 

Symptoms.- — Echinococcus  disease  may  extend  over  years  with- 
out giving  rise  to  symptoms.  Unless  there  is  infection  of  the  cyst, 
the  symptoms,  as  a  rule,  will  be  limited  to  the  effects  of  the  pressure 
exerted  by  the  tumor.  At  times  the  patient  may  complain  of  a  dull, 
dragging  feeling,  with  some  discomfort  and  slight  pain  in  the  epigas- 
trium, loin,  or  back.  When  the  cyst  is  large  and  situated  on  the  upper 
surface  of  the  liver,  pressure  on  the  diaphragm  may  cause  interference 
with  respiration.  In  such  cases  the  Hver  will  be  pushed  downward. 
When  the  cyst  grows  large  enough  to  interfere  with  the  normal  func- 
tions of  other  organs,  pressure  symptoms  referable  to  the  involved 
organs  will  be  noted.     Pressure  on  the  biliary  ducts  may  cause  jaundice ; 


564  SURGERY   OF   THE    LR'ER 

pressure  on  the  inferior  vena  cava  will  cause  ascites  or  edema  of  the 
lower  extremities;  pressure  on  the'  portal  vein  will  cause  gastro- 
intestinal varices  or  ascites;  pressure  on  the  gastro-intestinal  tract 
will  cause  functional  disturbances.  Attacks  of  urticaria  are  not 
uncommon. 

When  large  enough  to  be  palpable,  the  connection  of  the  tumor 
with  the  liver  is  evident;  its  surface  is  smooth  and  rounded,  impart- 
ing to  the  examining  lingers  the  sensation  of  a  dense  fluctuating 
mass.  When  the  tension  within  the  cyst  is  high,  fluctuation  is  not 
present  and  the  tumor  seems  a  solid  mass.  A  jelly-like  feel  is  absent 
in  the  great  majority  of  cases;  Finsen  was  unable  to  detect  it  in  a 
series  of  235  cases.  If  adhesions  are  present,  the  tumor  is  more  or  less 
fixed;  if  absent,  the  tumor  moves  with  respiration.  There  is  no 
tenderness  on  pressure,  as  a  rule,  unless  the  cyst  is  infected. 

Hydatid  fremitus,  a  tremulous  impulse  felt  in  palpation,  over 
a  hydatid  cyst,  may  or  may  not  be  elicited.  It  is  supposedly  caused 
by  the  impact  of  the  daughter-cysts  against  one  another.  If,  however, 
the  parent  sac  contains  fluid  the  daughter-cysts  will  be  suspended  and 
will  not  give  this  sign. 

A  sign  that  is  considered  pathognomonic  of  hydatid  disease  by 
Santoni  was  described  by  him  in  1894,  when  he  found  that  auscutatory 
percussion  revealed  a  peculiar  sound,  or  booming,  of  low  tone,  lasting 
but  a  short  time  and  ceasing  abruptly.  The  mass  is  dull  on  ordinarj' 
percussion. 

After  infection  of  an  echinococcus  cyst  has  taken  place,  the  symptoms 
presented  are  much  more  intense  and  generally  alarming.  The  patient 
becomes  septic,  with  irregular  temperature,  abdominal  pain  and  marked 
tenderness  over  the  region  of  the  tumor.  Symptoms  of  peritoneal 
irritation  usually  are  marked. 

The  symptoms  presented  in  echinococcus  disease  are  often  very 
misleading,  as  may  be  seen  from  the  following  case  history: 

L.  E.,  female,  aged  twenty-two.  Born  in  Russia;  hat-trimmer.  Admitted 
to  the  German  Hospital,  December  14,  1909.  Family  history  negative.  No  tuber- 
culosis. No  carcinoma.  Has  been  in  this  country  five  years.  Well  until  present 
illness.  No  acute  diseases,  no  operations.  Habitual  constipation.  Menstrual 
history  surgically  negative. 

Present  Illness. — Began  to  '"feel  badly"  two  days  before  admission,  com- 
plaining of  indigestion  which  she  had  had  at  irregular  intervals  during  past  three 
months.  Her  attacks  of  indigestion  began  about  two  hours  after  meals,  and  were 
characterized  by  a  sensation  of  discomfort  and  bloating  in  abdomen.  No  nausea 
or  vomiting.  Present  attack,  began  with  pain  in  epigastrium,  a  little  to  right  of 
median  line,  midway  between  costal  margin  and  umbilicus.     This  has  remained 


ECHINOCOCCUS    CYSTS  565 

the  most  acutely  painful  point,  but  pressure  over  any  portion  of  the  abdomen 
caused  pain.     Patient  had  never  been  jaundiced. 

Physical  Examination. — Well-developed  and  well-nourished  girl,  expression 
worried.  Face  flushed,  cheeks  hectic.  Knees  kept  fle-xed.  Respiration  costal. 
Head  negative.  Tongue  slightly  coated.  Chest  and  heart  negative,  .\bdomen 
full  but  not  distended.  Abdomen  generally  rigid  and  in  upper  portion  hard. 
Tender  everywhere.  Liver  dullness  completely  obliterated.  No  mass  palpable. 
No  marked  dullness  in  flanks.  Peristalsis  present.  Pelvis  normal  with  exception 
of  tenderness  on  pressure  throughout  vaginal  vault.  Pulse  rapid  but  regular, 
volume  small,  tension  high. 

Hb.  74  per  cent.;  leukocytes,  24,550;  polynuclears,  88.5  per  cent. 

Provisional  diagnosis  of  duodenal  ulcer  with  perforation  was  made,  and  opera- 
tion advised. 

Operation  on  day  of  admission.  Ether  anesthesia.  Upper  right  rectus  incision. 
Intestines  distended.  Stomach,  gall-bladder,  duodenum  and  pancreas  apparently 
normal  to  palpation  and  inspection.  Palpation  of  liver  revealed  a  nodule  situated 
in  the  left  lobe  on  upper  surface,  anteriorly.  Area  of  yellow-white  tissue  protruded 
from  surface,  about  the  size  of  top  of  wine-glass.  Incision  made  into  tumor,  through 
very  tough  wall.  Cavity  about  size  of  lemon  revealed.  Cavity  filled  with  echino- 
coccus  daughter-cysts,  not  infected.  Cavity  thoroughly  curetted  and  packed  with 
gauze.     Wound  closed  around  drainage. 

December  27,  1909:  Course  of  convalescence  normal.  All  gauze  removed 
to-day.     Cavity  in  liver  granulating. 

December  28,  1909:  Patient  up  and  around  ward,  talking  with  other  patients. 
Complained  of  sudden  sharp  pain  over  heart,  with  sudden  cessation  of  heart  action 
and  of  respiration.     Was  dead  within  four  minutes. 

Autopsy  revealed  a  second  cyst  about  the  size  of  a  lemon  situated  in  the  right 
lobe  of  the  liver.     No  evidence  of  peritonitis.     No  demonstrable  cause  of  death. 

Diagnosis. — It  is  practically  impossible  to  recognize  hydatid 
cysts  of  the  liver,  v^^hen  the  tumor  is  small.  When  the  cyst  is  palpable, 
its  evident  connection  with  the  liver,  and  its  generally  rounded,  smooth 
surface  are  suggestive  features.  Unless  fastened  in  place  by  ad- 
hesions, it  moves  with  respiration.  A  clear  history  of  the  course 
of  the  disease  from  the  first  symptom  presented  usually  helps  to  clear 
up  the  differential  diagnosis.  When  the  cyst  has  become  infected 
the  diagnosis  is  comparatively  easy,  especially  in  those  cases  where 
echinococcus  disease  is  known  to  exist.  There  will  be  marked  pain, 
an  irregular  temperature,  and  symptoms  of  peritoneal  irritation  in 
addition  to  those  formerly  presented  by  the  disease.  These  symptoms 
may  be  less  marked,  as  pointed  out  by  Kehr,  when  the  tumor  becomes 
adherent  to  the  abdominal  wall  and  threatens  to  break  through  the 
skin.  The  diagnosis  must  then  be  made  from  the  redness  and  the 
peculiar  condition  of  the  skin  and  subcutaneous  tissues,  together 
with  the  general  symptoms  presented. 


S66  SURGERY   OF   THE    LIVER 

In  reaching  a  diagnosis  of  hydatid  cyst,  the  usual  causes  of  tumors 
of  the  liver  must  be  considered  and  excluded.  Carcinoma,  abscess, 
syphilis  and  tuberculosis  are  the  underlying  causes  of  most  liver 
tumors.  Sarcoma,  lymphadenoma,  angeioma,  myxoma,  fibroma,  and 
atheroma  are  also  observed,  but  not  so  frequently.  Tumors  of  the 
adjacent  organs  must  also  be  considered.  Those  most  likely  to  throw 
doubt  on  the  diagnosis  are  tumors  of  the  gall-bladder,  of  either  kidney, 
or  of  the  spleen.  Empyema  and  subphrenic  abscess  may  also  be 
confounded  with  hydatid  cyst. 

Primary  carcinoma  (page  579)  of  the  liver  is  rare.  Usually  car- 
cinoma is  secondary  to  a  similar  growth  in  some  other  organ;  the 
presence  of  carcinoma  in  a  locahty  other  than  the  liver  makes  the 
diagnosis  of  carcinoma  of  the  liver,  when  a  tumor  of  that  organ  is 
discovered,  most  probable.  The  carcinomatous  tumor  is  more  ir- 
regular than  the  cyst,  presents  a  roughened  surface,  and  feels  harder 
than  the  cyst.  There  is  increasing  pain  in  the  region  of  the  liver, 
with  decrease  in  weight,  loss  of  appetite  and  of  strength.  Emaciation 
soon  becomes  marked,  while  the  liver  shows  increase  in  size,  and 
becomes  tender  to  the  touch.  Jaundice  may  be  early  or  late  in  the 
disease  and  always  increases  in  intensity. 

In  abscess  of  the  liver  (page  540)  a  palpable  tumor  may  develop 
either  in  the  epigastrium  or  beneath  the  right  costal  margin.  It 
is  tender  on  palpation,  usually  increases  rapidly  in  size,  and  gives 
marked  constitutional  symptoms,  such  as  chills,  sweating,  irregu- 
lar temperature,  and  a  peculiar  sallowness  of  the  face.  The  pre- 
vious history  usually  shows  an  antecedent  focus  of  pus  in  some  other 
region  of  the  body,  especially  in  the  appendix,  or  the  occurrence  of 
dysentery.  The  stools  should  be  carefully  examined  for  amebas;  a 
blood  examination  usually  shows  a  marked  increase  in  the  white  cells. 
This  is  not  the  case  in  an  uninfected  hydatid  cyst.  The  differential 
diagnosis  between  an  infected  suppurating  hydatid  cyst,  and  an 
abscess  of  the  Uver  often  is  extremely  dilScult,  and  depends  more 
upon  the  clinical  history  than  upon  the  physical  examination. 

Syphilitic  tumors  (page  576)  of  the  liver  are  much  more  common 
in  this  country  than  hydatid  cysts.  In  the  cases  of  recent  gum- 
mata,  there  usually  is  a  distinct  tumor,  either  in  the  form  of  a  hard 
nodule  or  a  large  flat  mass.  Usually  a  clear  history  of  specific  in- 
fection can  be  obtained.  In  every  instance  where  syphilis  of  the  liver 
is  suspected,  potassium  iodide  should  be  administered.  This  will  cause 
some  diminution  in  the  size  of  a  syphilitic  tumor,  although  it  may  not 
entirely  disappear.     The  Wassermann  test  also  should  be  made. 


ECHINOCOCCUS   CYSTS  567 

Tuberculosis  of  the  liver  at  times  may  cause  a  distinct  tumor,  as 
shown  in  the  case  reported  by  MacKenzie.  In  this  case  there  were 
multiple  abscesses  of  the  liver,  with  a  globular  swelling  about  the 
size  of  an  orange  in  the  right  lobe.  In  such  instances,  the  symptoms 
presented  are  similar  to  those  of  chronic  abscess  of  the  liver,  with 
acute  exacerbations. 

The  other  tumors  of  the  Hver  seldom  are  seen  and  do  not  pre- 
sent symptoms  which  would  allow  a  differentiation  from  the  non- 
infected  small  hydatid. 

In  empyema  and  subphrenic  abscess,  there  usually  is  a  history 
of  pneumonia,  pleurisy,  cholelithiasis,  cholecystitis,  appendicitis,  or 
some  other  lesion  which  leads  to  a  correct  differentiation  between 
the  condition  present  and  an  echinococcus  cyst. 

Ghedini  (1907)  claims  that  the  presence  of  an  echinococcus  cyst  in 
the  body  may  be  revealed  by  the  hemolytic  blood  test. 

Treatment. — Other  things  being  equal  surgical  treatment  is  in- 
dicated in  every  case  of  hydatid  cyst  of  the  liver  as  soon  as  the  diag- 
nosis is  made.  There  is  nothing  to  be  gained  by  waiting,  and  medi- 
caments are  totally  powerless  to  destroy  the  worm.  It  will  be  con- 
venient to  study  first  the  treatment  of  the  simple,  noninfected, 
hydatid  cyst  of  the  hver;  and  then  to  discuss  the  proper  treatment 
of  the  various  compUcations  that  may  arise  (suppuration,  rupture, 
etc.).  The  methods  for  prophylaxis  have  already  been  mentioned 
(page  560). 

Method  of  access  for  evacuation  of  an  echinococcus  cyst  de- 
serves a  few  words.  Most  cysts  develop  downward  and  are  best 
exposed  by  laparotomy;  resection  of  the  costal  border  or  division 
of  the  suspensory  Hgament  may  be  necessary  for  better  exposure. 
For  those  .growing  upward  beneath  the  diaphragm  the  operation 
is  similar  to  that  for  the  drainage  of  an  abscess  of  the  Uver  by  the 
transpleural  route  (Israel,  1879).  Roser  claims  that  he  proposed 
this  plan  as  early  as  1864. 

Treatment  of  Single  Uncomplicated  Cysts. — Puncture  or  aspiration 
of  the  contents  of  the  cyst  was  the  earliest  form  of  surgical  treatment 
adopted.  The  fact  that  cures  were  reported  from  these  simple 
methods  merely  shows  that  the  patients  were  not  kept  under  ob- 
servation long  enough  after  operation  to  exclude  the  possibiUty  of 
recurrence.  This  may  not  take  place  for  many  months,  or  even 
years.  If  infection  occurred,  either  before  or  after  inspiration,  it 
was  recommended  to  open  the  cyst  widely  and  drain  it;  under  such 
circumstances  it  usually  was  adherent  to  the  abdominal  wall.     The 


568  SURGERY    OF    THE    LIVER 

method  of  opening  and  drainage  appears  first  to  have  been  erected 
into  a  principle,  applicable  to  all  echinococcus  cysts  of  the  liver,  by 
Landau  in  1880;  the  procedure  is  termed  marsupialization  of  the 
cyst,  that  is,  converting  it  into  a  pouch. 

MarsupializatioH. — The  cyst  is  exposed  by  laparatomy,  its  walls 
are  sutured  to  the  edges  of  the  abdominal  incision,  and  it  is  opened 
then  or  at  a  subsequent  operation.  Its  contents  are  evacuated,  includ- 
ing detached  daughter-cysts,  and  such  scolices  as  have  escaped  from 
their  brood-capsules;  the  inner  capsule  of  the  cyst  (germinal  layer)  is 
also  removed.  The  outer  capsule  should  not  be  disturbed;  it  is  closely 
surrounded  in  most  cases  by  dilated  biliary  channels  (perhaps  contain- 
ing infected  bile)  and  by  blood-vessels  (especially  portal  or  supra- 
hepatic  veins)  of  unknown  size  which  may  give  rise  to  troublesome  or 
even  fatal  hemorrhage.  The  cyst  having  been  thus  emptied,  its  cavity 
is  stuffed  with  gauze,  and  allowed  to  heal  by  granulation.  Though 
the  immediate  mortahty  of  this  operation  is  low,  Cauchoix  (1908) 
noting  ten  deaths  among  185  operations  recorded  by  Vegas  and 
Cranwell  (1901),  it  has  manifest  disadvantages  in  the  form  of  post- 
operative comphcations,  which  no  longer  commend  it  to  surgeons. 
Chief  of  these  objections  is  the  long  period  of  convalescence:  Cauchoix 
found  that  though  the  great  majority  of  cysts  were  completely  closed 
in  from  one  to  four  months,  yet  that  in  many  patients  the  fistula  con- 
tinued to  discharge  for  six  months  or  a  year.  Moreover,  it  is  very 
difiicult  to  prevent  secondary  infection  when  marsupiahzation  is  em- 
ployed, the  case  being  analogous  to  that  of  a  cold  abscess  opened  and 
drained;  and  suppuration  in  an  opened  hydatid  cyst  may  become  a  very 
serious  matter.  The  secondary  discharge  of  bile  which  often  occurs 
through  the  fistulous  tract  may  seriously  impair  the  patient's  health. 
These  biliary'  discharges  as  well  as  spontaneous  hemorrhages  into  the 
opened  cyst,  are  due  to  the  negative  pressure  created  in  the  cyst  by 
opening  and  drainage. 

Suture  of  the  incision  in  the  cyst,  after  the  evacuation,  and  closure  of 
the  abdominal  wound,  was  a  method  introduced  in  1883  by  Knowsley 
Thornton  and  popularized  in  1891  by  Bond.  The  sutured  incision  in 
the  cyst-wall  was  fixed  to  the  abdominal  wound.  In  this  way  it  was 
hoped  to  avoid  the  disadvantages  attendant  upon  prolonged  drainage,  at 
the  same  time  permitting  secondary  opening  and  drainage  of  the  cyst 
should  occasion  demand. 

Reduction  of  the  evacuated  cyst,  without  suture  of  the  incision  in  its 
walls,  and  closure  of  the  abdominal  wound  without  drainage,  was 
employed  by  Ryan  and  by  Hamilton  Russell  in  1894  and  adopted  by  a 


ECHINOCOCCUS   CYSTS  569 

few  other  surgeons;  but  the  dangers  of  secondary  infection  of  the 
peritoneum  through  bile  or  blood  effused  into  the  cavity  of  the  un- 
sutured  cyst  soon  caused  this  method  to  be  abandoned. 

Endocystorrhaphy  (Capitonnage)  was  adopted  in  1896  by  Delbet 
and  by  Posadas.  They  diminished  but  did  not  entirely  obliterate 
the  cavity  of  the  cyst,  after  its  evacuation,  by  interrupted  sutures, 
cautiously  passed  through  its  walls.  The  cyst  was  completely  closed, 
and  was  fixed  to  the  abdominal  wound,  which  was  sutured  without 
drainage. 

Enucleation  of  the  cyst  from  the  surrounding  hepatic  tissue  has  been 
employed  in  a  few  cases;  but  the  danger  of  opening  into  blood  or  bile- 
channels  renders  it  a  most  unsuitable  method.  Cauchoix  refers  to 
fourteen  cases,  in  four  of  which  the  operation  could  not  be  completed. 

Extirpation  of  the  cyst  may  be  done  when  it  is  pedunculated; 
or  a  small  portion  situated  within  the  liver  may  be  removed  by  partial 
hepatectomy.  Fowler  prefers  this  to  any  other  method,  whenever 
practicable.  Its  advantages  are  a  shortened  convalescence,  freedom 
from  a  biliary  fistula,  and  assurrance  that  the  entire  disease  has  been 
removed. 

Prophylactic  Treatment  {Formalization). — Under  this  title,  Cauchoix 
describes  a  method  of  sterilization  of  the  cyst  contents  by  injection  of  a 
I  per  cent,  formalin  solution  with  the  view  of 
preventing  recurrence  of  the  disease.  It  was 
demonstrated  experimentally  by  Deve  (These 
de  Paris,  1901)  that  each  of  the  parasitic  ele- 
ments contained  in  echinococcus  cysts  is  capable 
of  reproducing  the  primary  lesion ;  and  Cauchoix 
showed  that  such  recurrence  occurred  clinically, 
though  often  not  for  years  after  the  primary 
operation.  After  various  other  antiseptics  had 
been  tried  with  no  very  marked  success,  Quenu 
(1902)  adopted  formalin  solution  (i  per  cent.)  as  ^.^  is4._or6nu's  Method 
the  sterilizing  fluid,  and  employed  the  following  o'  Formoiization  of  Hydatid 

,      ,      .  .   '  ,  J.  .,  ,      J    Cysts  (Ashhurst). 

technique  in  a  number  of  cases  with  marked 

success:  The  cyst  was  exposed  by  laparotomy,  and  thoroughly  isolated 
by  gauze  packing.  The  fluid  contents  of  the  cyst  were  then  with- 
drawn through  a  trocar  and  canula  by  syphonage  into  a  funnel. 
To  avoid  possibility  of  soihng  the  surrounding  tissues,  a  very  fine 
canula  was  employed  and  the  trocar  was  passed  through  the  wall  of 
the  rubber  tubing  attached  to  the  end  of  the  canula,  so  that  when 
it  was  withdrawn  no  leakage  occurred  in  its  tract  (Fig.  154).     When 


570  SXJRGERY   OF    THE    LIVER 

the  cyst  has  been  thus  evacuated,  the  funnel  is  emptied,  and  is  then 
filled  with  the  formaUn  solution  which  is  allowed  to  enter  and  distend 
the  cyst,  by  the  force  of  gravity.  This  solution  is  left  in  the  cyst 
for  five  minutes,  and  is  then  withdrawn.  The  cyst,  thus  sterilized, 
is  incised  freely,  and  the  germinal  membrane  is  removed.  Repeated 
laboratory  examinations  of  this  membrane  showed  that  all  parasitic 
elements  had  been  killed  by  the  formalin  solution.  The  cyst  there- 
fore may  be  closed  with  impunity,  restored  to  the  abdomen  and  the 
external  wound  closed  without  drainage.  It  always  is  well,  however, 
to  fix  the  cyst-wall  to  the  abdominal  wound  so  that  should  an  intracystic 
effusion  of  bile  or  blood  demand  evacuation  this  can  be  accomplished 
wathout  wide  opening  of  the  peritoneal  ca\-ity. 

This  prophylactic  treatment  ofQuenu  undoubtedly  is  the  best  method 
of  operation  in  all  cases  to  which  it  is  applicable;  but  there  are  a  few  to 
which  it  is  not  suited:  cases,  for  example,  when  the  hydatid  cyst  is  full 
of  daughter-cysts  and  contains  no  fluid,  so  that  it  cannot  be  evacuated 
by  puncture.  In  such  circumstances  Cauchoix  recommends  that  the 
surrounding  tissues  be  protected  by  gauze  soaked  in  formalin,  so  that 
the  parasitic  elements  unavoidably  discharged  over  the  field  of  operation 
may  be  promptly  killed. 

Treatment  of  Complicated  Cysts. — This  subject  has  been  well 
studied  by  Cauchoix  (1908)  and  we  have  made  free  use  of  his  valuable 
memoir  in  what  follows. 

Suppurating  hydatid  cysts  require  the  same  treatment  as  abscesses 
of  the  liver;  but  when  the  infection  is  of  very  low  grade,  as  manifested 
by  the  cHnical  history,  it  may  be  possible  to  close  the  cyst  completely 
after  the  use  of  a  formahn  injection,  or  at  least  to  suture  the  incision 
tightly  around  a  drainage  tube  which  may  be  removed  in  about  four 
days.  According  to  Vegas  and  Cranwell  the  mortality  in  cases  of 
suppurating  cysts  treated  by  marsupialization  is  from  20  to  30  per  cent. 

Rupture  of  a  cyst  into  the  peritoneum  requires  immediate  laparotomy 
and  drainage,  both  of  the  cyst  and  of  the  pelvis.  This  is  true  not  only 
in  the  case  of  rupture  of  a  suppurating  cyst,  but  also  when  an  aseptc 
cyst  ruptures,  because  in  the  latter  case  the  secondary  development  of 
peritonitis  from  effusion  of  bile  (choleperitonitis)  is  much  to  be  feared. 

Rupture  of  a  cyst  into  the  intestine  is  dangerous  because  of  the  secon- 
dary infection  of  the  cyst  which  is  nearly  sure  to  occur.  The  proper 
treatment  is  laparotomy  so  soon  as  the  immediate  shock  of  the  accident 
subsides,  with  repair  of  the  intestinal  defect  and  drainage  of  the  cyst. 
Rupture  occurs  oftenest  into  the  duodenum,  transverse  colon  or 
stomach. 


ECHINOCOCCUS    CYSTS  571 

Compression  of  the  biliary  ducts  by  an  echinococcus  cyst  leads  soon 
to  a  condition  of  angeiocholitis,  which  demands  choledochotomy  and 
hepaticus  drainage  in  addition  to  the  treatment  appropriate  to  the 
cyst  itself. 

Rupture  of  a  cyst  into  the  biliary  passages  is  by  no  means  rare. 
It  was  carefully  studied  by  Quenu  and  Duval  in  igo6.  In  most 
cases  this  occurrence  is  attended  by  severe  pain,  and  the  appearance  of 
septic  symptoms,  chills  and  fever.  Unless  the  existence  of  a  hydatid 
cyst  is  already  known,  the  recognition  of  such  a  compHcation  would 
be  very  difficult.  The  common  duct  may  be  obstructed  by  the  impac- 
tion of  some  of  the  cyst  contents,  or  merely  by  inflammatory  swelling. 
Usually  choledochotomy  and  hepaticus  drainage  will  be  required,  in 
addition  to  proper  treatment  of  the  cyst.  In  six  operations  in  which 
cholecystostomy  was  done,  with  drainage  of  the  cyst,  there  were  two 
deaths.  In  eight  operations  on  the  common  duct  there  were  three 
deaths  (Quenu). 

Rupture  of  a  cyst  into  the  thoracic  cavity  is  another  very  fatal  com- 
pKcation.  Even  if  it  ruptures  only  into  the  pleura,  symptoms  of 
pulmonary  distress  are  usual;  the  pleural  effusion  is  blie  stained 
(cholethorax) ,  owing  to  leakage  of  bile  into  the  cyst  cavity.  Cauchoix 
collected  five  cases,  with  three  deaths.  The  proper  treatment  is 
pleurotomy,  with  free  drainage,  and  marsupialization  of  the  cyst. 
If  rupture  into  the  lung  or  bronchial  tubes  occurs,  death  is  almost 
inevitable.  Treatment  is  the  same  as  for  pulmonary  abscess;  the 
hepatic  cyst  should  be  drained  also,  preferably  through  the  thoracic 
wound. 

The  mildly  infectious  nature  of  some  suppurating  hydatid  cysts 
is  exempHfied  in  the  following  case,  in  which  the  cyst  was  opened 
and  drained  without  infecting  the  general  peritoneal  cavity. 

M.  B.,  male,  aged  twenty-two,  born  in  Austria-Hungary,  admitted  to  the 
German  Hospital  (Medical  Department),  October  15,  1909.  Came  to  the  United 
States  three  years  ago,  since  which  time  he  has  been  employed  as  a  butcher.  Denies 
venereal  infection.  Family  history  negative.  Had  attacks  similar  to  present, 
eight  years  ago.     Has  had  no  other  illness  of  any  kind. 

Present  illness  began  two  weeks  before  admission.  Had  sudden  attack  of 
severe  abdominal  pain,  greater  in  epigastrium  and  radiating  across  upper  abdomen 
and  into  back.  Pain  severe  and  lasted  several  hours.  There  was  some  epigastric 
swelling.  Vomited  after  eating.  Took  castor  oil  and  felt  better.  Had  second 
attack  five  days  before  admission,  with  vomiting.  Third  attack  began  day  before 
admission,  and  lasted  two  hours.  Vomited  after  drinking  glass  of  milk.  During 
attack  of  pain  felt  hot  and  cold  alternately  and  had  a  slight  chill.  Appetite  re- 
mained good.     Bowels  fairly  regular  until  lately. 


572  SURGERY    OF    THE    LIVER 

Physical  Examination. — Fairly  well-nourished  man,  face  covered  with  acne. 
Tongue  heavily  coated  in  middle  and  back.  Teeth  in  fair  condition.  Head, 
lungs  and  heart  negative.  Abdomen  flat.  Liver  extends  from  fifth  interspace 
to  6  cm.  below  costal  margin.  Edge  rounded.  In  epigastrium  and  slightly 
to  left  is  a  mass  with  rounded  edges,  firm  in  consistence,  tender  on  pressure.  Moves 
with  respiration.     .Spleen  not  palpable.     No  rose  spots.     E.Mremities  negative. 

October  i6,  1909;  Yellowish-brown,  liquid  stool.  Occult  blood  absent.  Trace 
of  bile.  Alkaline  reaction.  Soaps,  neutral  fats  and  fatty  acid  crystals.  Many 
yeast  ceDs.     Few  epithelial  cells. 

Stomach  test-meal:  Semi-liquid  stomach  contents,  not  completely  digested. 
Acid  in  reaction.  Free  hydrochloric  acid,  sixty-four.  Total  acidity,  ninety. 
Occult  blood  absent.  Bile  absent.  Starch,  neutral  fats,  epithelium,  yeast  cells 
present. 

X-ray  examination  showed  shadow  to  right  of  median  line  extending  from  right 
costal  margin  half  way  to  umbilicus,  aftected  slightly  by  deep  inspiration.  Con- 
tinuous with  liver  shadow. 

October  20,  1909:  Hemoglobin,  95  per  cent.;  leukocytes,  11,200. 

October  26,  1909:  Temperature,  99°;  respiration,  24;  pulse,  84. 

October  27,  1909:  Temperature,  103°;  respirations,  26;  pulse,  104.  Patient 
seized  with  attack  similar  to  those  described.  Severe  pain  in  upper  abdomen 
radiating  to  back  followed  by  rise  of  temperature  and  pulse  rate.  Swelling  in 
epigastrium  very  tender.  Has  persisted  and  extended  more  to  right.  Leukocytes, 
16,500.  Polynuclears,  84  per  cent.;  lymphocytes,  8.5  per  cent.;  mononuclears, 
1.5  per  cent.;  eosinophiles,  2  per  cent.;  basophiles,  o  per  cent.;  transitional,  3.5  per 
cent.;  unidentified,  0.5  per  cent. 

Transferred  to  surgical  ward.  Patient  lies  on  side  with  head  down  and  knees 
drawn  up.  Swelling  in  epigastrium  visible,  about  size  of  an  orange,  exceedingly 
tender,  dull  on  percussion,  evidently  continuous  with  liver.  Moves  very  slightly 
with  respiration. 

Operation  by  Dr.  Deaver,  October  30,  1909:  Ether  anesthesia.  Upper  right 
rectus  incision.  Left  lobe  of  liver  found  lower  than  usual,  the  convexity  being 
boggy.  Few  adhesions  between  left  lobe  and  surrounding  structures.  In  libera- 
ting the  adhesions,  waO  of  a  purulent  collection  in  the  left  lobe  was  ruptured  and 
thin  stream  of  pus  was  liberated.  Attempts  at  aspiration  were  futile.  Surrounding 
region  well  protected  by  means  of  gauze  pads,  mass  incised  and  large  quantity 
of  pinkish-yellow  faintly  odorous  fluid  liberated.  The  fluid  contained  many  white 
cyst-like  bodies  in  a  state  of  coUapse,  resembling  white  grape  skins,  varying  in  size 
from  a  small  pea  to  a  bird's  egg.  About  a  pint  of  material  removed.  A  cavity 
about  the  size  of  a  large  fist  remained.  This  was  curetted  carefuUy,  and  then  drained 
with  large  rubber  tube  and  gauze  packing.     Wound  closed  to  edge  of  drainage. 

November  12,  1909:  All  gauze  removed  under  primary  chloroform  anesthesia. 
Gauze  packing  introduced. 

November  22,  1909:  Gauze  removed,  followed  by  cyst-waU. 

November  26,  1909:  Cavity  granulating.     Wound  discharging  considerable  bile. 

Discharged  from  hospital  December  24,  1909,  with  small  sinus.  No  discharge 
of  bOe. 

Temperature  ran  an  irregular  course,  until  the  nineteenth  day  after  operation, 
when  it  reached  normal  and  remained  so. 


NON-PARASITIC   CYSTS  573 

Non-parasitic  cysts  of  the  liver  ma>-  be  di\ided  into  two  classes, 
the  congenital  and  the  acquired.  Among  the  former  are  dermoid 
cysts  and  multiple  epithelial  cysts.  The  former  are  operable.  The 
latter  are  of  interest  mainly  from  a  diagnostic  point  of  view,  as  they  are 
inoperable  and  a  fatal  result  usually  occurs  from  the  "cystic  degenera- 
tion" of  the  hver,  which  is  frequently  found  associated  with  cystic 
degeneration  of  other  organs  such  as  the  kidneys,  ovaries,  etc.  Death 
usually  results  from  obstruction  of  the  portal  vein.  When  such  cystic 
disease  of  the  hver  is  discovered  at  operation,  further  operative  pro- 
cedure is  contraindicated. 

Kehr  quotes  Pellman  as  dividing  into  five  classes  the  non-parasitic 
cysts  of  the  liver  which  may  be  treated  by  operation: 

1.  Retention  cysts  of  the  biliary  tract. 

2.  Cysts  lined   with   ciliated   epithelium,   said   by   von   Reck- 
linghausen to  be  due  to  retention  of  mucus. 

3.  Dermoid  cysts. 

4.  Epithelial  cysts,  or  cystadenomata. 

5.  Lymph  cysts. 

The  symptoms  produced  by  any  of  these  various  classes  of  cysts  are 
similar  to  those  of  the  non-infected  echinococcus  cyst  (page  563). 
These  cysts  may  attain  considerable  size,  and  then  may  be  mistaken  for 
cystic  conditions  of  the  kidney  or  ovary.  The  differental  diagnosis  is  to 
be  made  from  study  of  the  symptoms  presented,  together  with  the  ana- 
tomical diagnosis  of  the  organ  involved.  Non-parasitic  cysts  of  the 
liver  cannot  be  dift'erentiated  before  operation  from  echinococcus  cysts 
of  the  liver,  and  often  it  is  necessary  to  depend  upon  the  microscopical 
examination  of  the  contents  or  of  a  section  of  the  cyst-wall  for  a  correct 
diagnosis.  It  is  not  justifiable  in  any  instance  to  make  an  exploratory 
puncture  for  the  purpose  of  diagnosis. 

Treatment. — The  treatment  consists  in  the  removal  of  the  cyst 
contents  and  of  as  much  of  the  cyst-wall  as  is  possible.  In  pedancu- 
lated  cysts,  the  entire  mass  usually  may  be  removed.  When  the  cysts 
are  deep  seated,  an  incision  through  the  liver  substance  must  be  made, 
down  to  the  cyst-wall,  when  it  will  be  found  feasible  to  shell  out  many 
of  them,  without  rupture,  owing  to  the  fact  that  the  cyst-wall  usually 
is  dense.  When  rupture  during  removal  does  occur,  there  is  less  danger 
of  serious  infection  than  from  a  ruptured  echinococcus  cyst.  The  post- 
operative course  and  treatment  are  similar  to  those  following  the 
operation  for  echinococcus  cyst.  Boyd  (1913)  collected  34  operations 
for  non-parasitic  cysts  of  the  liver,  with  11  deaths. 


CHAPTER  XIX 

TUMORS  OF  LIVER,  GALL-BLADDER  AND  BILE-DUCTS 

Tumors  of  the  liver,  apart  from  those  of  the  gall-bladder  and  bile- 
ducts,  have  little  practical  interest  for  the  surgeon.  They  are  impor- 
tant, however,  from  the  aspect  of  diagnosis;  but  only  in  a  few 
exceptional  cases,  so  far,  has  it  been  possible  for  the  surgeon  to  attempt 
any  radical  cure  by  means  of  operation.  It  is  possible  that  the  future 
will  breaden  this  field  of  hepatic  surgery  so  that  relief  may  be  afforded 
a  greater  number  of  sufferers  from  hepatic  tumors. 

Benign  Solid  Tumors  of  the  Liver 

With  the  possible  exception  of  adenoma,  benign  solid  tumors 
of  the  liver  are  surgical  rarities.  Angeiomata,  fibromata,  myomata, 
etc.,  have  been  obser\-ed  but  are  principally  of  pathological  inter- 
est. As  pointed  out  by  Mayo  (1908)  a  diffuse  or  circumscribed  angeio- 
matous  condition  of  the  liver  sometimes  is  found  during  operations 
on  the  bile-passages  and  troublesome  hemorrhage  may  result  if  injury 
occurs  to  the  dilated  blood-vessels  forming  the  tumors. 

Adenoma  of  the  liver  is  a  comparatively  rare  neoplastic  growth, 
of  very  obscure  origin.  It  is  not  an  uncommon  postmorten  find- 
ing, although  unfrequently  recognized  clinically.  Gordinier  and 
Sawyer  (1913)  collected  forty-four  cases  reported  by  various  observers. 
Cushing  and  Downs  (1899)  found  seven  cases  of  adenomata  reported 
among  seventy-five  operations  for  tumor  of  the  liver.  Adenomata 
may  occur  at  any  age,  cases  having  been  reported  in  patients  twenty 
months  and  seventy-six  years  of  age  respectively.  Of  twenty-nine 
cases,  collected  by  Marckwald  (1896),  twenty-three  were  in  patients  of 
the  male  sex. 

Pathology.- — Adenoma  of  the  liver  is  a  primary  growth  and  two 
varieties  are  recognized:  the  nodular  adenomatous  hyperplasia  of  the 
liver,  which  is  not  amenable  to  surgical  treatment;  and  the  circum- 
scribed tubular  adenoma  (Langenbuch) .  Among  the  forty-four  cases 
mentioned  above,  twenty-eight  were  multiple  and  sLxteen  solitary. 

In  nodular  adenomatous  hyperplasia  which  usually  is  associated 
with  cirrhosis  of  the  liver  (Simmons,  1877)  there  is  a  roughened  nodular 
condition  of  the  surface  of  this  organ.     Cross-sections  of  the  liver 

574 


BENIGN    SOLID    TUMORS    OF    LIVER  575 

show  pathological  masses  of  abnormal  color,  not  definitely  encapsulated 
but  separated  from  each  other  by  fibrous  changes  in  the  parenchyma 
(cirrhosis).  Pathologists  are  not  agreed  whether  the  cirrhosis  causes 
the  development  of  these  multiple  adenomata  (as  a  compensatory 
hypertrophy),  the  view  held  by  Rolleston  (1905);  or  whether  both 
pathological  changes  are  due  to  the  same  original  irritant,  as  maintained 
by  Engelhardt  (1898)  and  by  Dieulafoy  (1901).  Brissaud  (1885) 
followed  Schuppel  (1875)  who  held  that  adenoma  is  a  stage  between  cir- 
rohis  and  carcinoma. 

The  tubular  adenoma  may  be  single  or  multiple,  usually  the  latter. 
The  tumors  usually  are  small,  though  one  may  reach  the  size  of  a  large 
orange.  The  larger  the  tumor  the  more  distinct  is  its  encapsulation. 
They  are  grayish-white  or  yellow  in  color,  unless  hemorrhage  has  oc- 
curred into  the  substance  of  the  tumor,  when  it  has  a  reddish  tinge,  or 
when  it  has  been  stained  green  by  bile.  The  larger  the  tumor  the  more 
apt  is  internal  hemorrhage  to  occur.  Cysladenoma  may  develop  in  this 
way  or  may  result  from  degenerative  changes.  Metastasis  is  very  rare 
but  Langenbuch  (1897)  refers  to  a  few  reported  instances. 

Adenoma  of  the  liver  may  be  derived  from  (a)  liver  cells,  {b)  the 
intrahepatic  bile-ducts,  or  (c)  from  adrenal  rests  in  the  liver  (Rolleston). 
The  larger  tumors,  and  particularly  those  which  become  cystic,  usually 
are  derived  from  the  bile-ducts.  Those  springing  from  the  hepatic 
cells  sometimes  contain  tubules  Hned  with  cubical  epithelium,  thus 
resembhng  primary  carcinoma  with  cirrhosis.  In  cases  of  adenoma 
of  the  liver  reported  by  Keen  (1893),  and  by  J.  B.  Roberts  (1894), 
it  was  found  that  the  adenomatous  change  was  due  to  proliferation  of 
coccidia. 

The  symptoms  of  adenomata  are  chiefly  those  of  cirrhosis  of  the 
liver,  the  symptoms  being  produced  by  compression  of  the  vessels  and 
bile-ducts.  In  the  early  stages  no  symptoms  may  be  produced,  but  as 
the  tumor  increases  in  size  digestive  disorders  arise,  accompanied  by 
dull  pain  in  the  hepatic  region,  followed  by  jaundice  and  emaciation. 
Other  symptoms,  due  to  interference  with  the  portal  circulation,  often 
develop;  varicosities  of  the  abdominal  veins  may  be  seen  and  ascites 
develops  rapidly.  In  advanced  cases  a  hard,  circumscribed  mass  may 
be  felt,  at  times  pendulous,  but  moving  freely  with  the  Uver  during 
respiration.  In  single  tumors,  the  liver  may  be  of  normal  size,  but  in 
multiple  adenoma  the  liver  is  enlarged  and  nodular. 

The  prognosis  is  bad  unless  extirpation  is  possible  before  the 
development  of  obstructive  symptoms.  But  the  condition  may  exist 
for  a  long  time  without  giving  rise  to  symptoms  of  any  kind. 


576  TUMORS    OF    LIVER,    GALL-BLADDER    AND   BILE-DUCTS 

The  treatment  is  palliative  in  nodular  adenomatous  hyperplasia. 
Even  in  the  case  of  single  adenoma,  operative  interference  is  con- 
traindicated  after  the  onset  of  jaundice  and  ascites.  In  the  earlier 
stages,  exploratory  laparotomy  should  be  done:  if  the  tumor  is  in  a 
favorable  location  and  easily  accessible,  it  should  be  removed  by 
partial  hepatectomy.  The  operative  mortality  is  about  15  per  cent, 
(page  582). 

Gummata  of  the  liver  usually  are  discussed  in  connection  with 
hepatic  neoplasms;  they  occur  as  single  or  multiple  nodules  varying 
in  size  from  a  pea  to  a  hen's  egg.  They  are  of  interest  to  the  surgeon 
from  a  diagnostic  standpoint,  operative  interference  seldom  being 
adopted  except  in  cases  where  a  wrong  diagnosis  has  been  made, 
or  for  degeneration  or  calcification  ot  the  gummatous  nodules.  When 
first  formed  the  gumma  is  soft;  later  a  central  area  of  necrosis  appears, 
and  if  healing  is  uninterrupted,  a  stellate  fibrous  cicatrix  results,  which 
is  quite  characteristic  and  usually  easily  recognized.  Sometimes 
the  gumma  becomes  calcified.  It  very  rarely  undergoes  liquefaction 
necrosis  or  suppuration  from  secondary  infection.  The  larger  nodules 
are  fo*und  principally  on  the  surface  of  the  Uver,  in  the  vicinity  of  the 
suspensory  Ugament,  although  they  may  occur  along  the  free  border 
or  along  the  upper  surface  of  the  right  lobe.  Occasionally  they  are 
pedunculated  (Cumston,  1903)  and  may  be  mistaken  for  a  linguiform 
lobe  (page  535)  or  a  floating  liver.  Between  the  gummata  may  be 
found  cicatricial  bands,  which  penetrate  into  the  liver  in  the  form  of 
deep  furrows.  When  these  are  present  in  great  numbers  a  condition 
known  as  botryoid  liver  results,  the  organ  being  divided  into  lobulated 
masses  separated  by  the  cicatricial  bundles. 

The  symptoms  of  gummata  of  the  liver  rarely  are  conspicuous. 
As  a  rule  the  Hver  is  enlarged  and  this  forms  the  most  constant  symp- 
tom. Pain  may  be  present  on  account  of  the  involvement  of  the 
serosa.  At  times  a  friction  rub  may  be  detected.  In  the  cicatricial 
stages,  pain  is  almost  constant,  being  of  a  very  dragging  character, 
and  referred  to  the  hepatic  region,  sometimes  to  the  right  shoulder. 
In  these  cases  there  is  almost  constant  discomfort,  exacerbations  or 
pain  being  noted.  Fever  is  never  present  unless  there  is  breaking 
down  and  ulceration  of  the  gumma.  Kirchheim  (1911)  reported 
three  cases  of  febrile  syphilitic  lesions  in  the  liver,  all  three  involving 
the  adjoining  diaphragm;  in  one  case  there  was  perforation  of  this 
structure  followed  by  empyema  and  chronic  inflammation  of  the 
lower  lobe  of  the  right  lung;  pleurisy  with  effusion  developed  in  the 
second  case;  in  the  third  case  although  the  diaphragm  was  involved 


SARCOMA    OF    LIVEK  577 

no  thoracic  symptoms  developed,  but  the  patient  died  from  perfora- 
tive peritonitis. 

Jaundice  is  rare  and  occurs  only  in  those  cases  where  there  is 
diffuse  syphilitic  involvement  of  the  liver. 

The  diagnosis  depends  on  the  history  of  the  patient,  on  the  dis- 
covery of  other  syphilitic  lesions  or  the  evidence  of  past  lesions;  on 
the  presence  of  the  Wassermann  reaction;  and  on  the  therapeutic 
test  of  antisyphilitic  remedies.  Gummata  of  the  liver  must  be 
distinguished  especially  from  disease  of  the  gall-bladder,  and  from 
carcinoma.  The  former  usually  may  be  excluded  by  a  careful  study 
of  the  history.  In  carcinoma  the  disease  does  not  extend  over  so 
long  a  time;  there  is  no  enlargement  of  the  spleen  (common  in  syphilis 
of  the  liver);  and  the  patient  very  seldom  is  under  forty  years  of 
age.  At  operation  the  differentiation  from  carcinoma  may  be  difficult, 
but  carcinoma  of  the  liver  almost  always  is  secondary  to  a  primary 
growth  elsewhere;  there  never  are  scars  of  healed  lesions  on  the  surface 
of  the  liver  as  is  frequently  the  case  in  syphilis  of  the  liver;  the  car- 
cinomatous nodules  often  stand  forth  prominently  from  the  surface  of 
the  liver;  and  when  cut  and  scraped  the  carcinoma  gives  "cancer 
juice"  which  is  never  the  case  with  a  gumma. 

Treatment. — The  usual  antisyphilitic  measures  should  be  instituted. 
If  the  patient's  condition  is  urgent,  arsphenamin  should  be  administer- 
ed. In  most  cases  the  vigorous  use  of  mercury  and  the  iodides  will 
bring  relief  of  symptoms.  If  such  treatment  fails,  as  it  usually  does 
when  the  gumma  is  very  fibrous  or  calcified,  excision  of  the  portion 
of  the  hver  affected  should  -be  attempted.  Lotheissen  (1912)  sum- 
marized the  results  of  forty  such  operations;  thirty-four  patients 
were  cured,  two  were  improved,  while  four  died.  These  forty  cases 
do  not  include  simple  exploratory  operation,  with  separation  of 
adhesions,  but  only  cases  of  excision. 

Tuberculoma  of  the  liver  is  rare.  Lotheissen  (191 2)  collected 
thirty-four  cases,  as  well  as  thirteen  cases  in  which  there  was  a  tuber- 
culous abscess  in  or  near  the  liver.  In  thirty-two  instances  the  lesions 
in  the  liver  were  found  only  at  autopsy;  and  in  twenty- three  there 
had  been  no  symptoms  during  life  to  call  attention  to  the  liver.  Opera- 
tive treatment  was  undertaken  in  fifteen  cases,  but  a  correct  diagnosis  be- 
fore operation  was  made  in  only  three.     Ten  of  these  patients  recovered. 

Malignant  Tumors  of  the  Liver 

Sarcoma  of  the  liver  is  very  rare  and  clinically  cannot  be  dis- 
tinguished from  carcinoma.     In  almost  all  cases  it  is  secondary  to 

37 


578  TUMORS    OF    LIVER,    GALL-BLADDER   AND   BILE-DUCTS 

sarcoma  in  some  other  part  of  the  body,  particularly  the  eye,  and  soft 
tissues  of  the  limbs.  There  are  a  few  cases  on  record  in  which  sar- 
coma of  the  hver  has  been  secondary  to  a  primary  sarcoma  of  bone, 
but  in  none  of  these  was  there  any  osseous  tissue  in  the  nodules  found 
in  the  Hver.  Langenbuch  (1897)  refers  to  two  instances  of  secondary 
chondrosarcoma  of  the  liver.  Most  tumors  are  spindle  or  round  celled. 
Lymphosarcoma,  myosarcoma,  and  myxosarcoma  also  have  been  re- 
corded. Melanotic  sarcoma  is  not  very  rare,  especially  when  second- 
ary to  a  similar  tumor  of  the  eye  (choroid). 

Knott  (19 10)  collected  fifty-nine  cases  of  primarj^  sarcoma  of  the 
liver,  and  reported  fifteen  hitherto  unpublished  cases,  making  a  total 
of  seventy-four  cases. 

The  symptovis  are  not  characteristic.  Pain,  enlargement  of  the 
liver,  perhaps  jaundice  and  ascites,  may  develop  until  late  in  the 
disease.  Kahlden  (1897)  reported  a  case  in  which  the  first  symptom 
was  the  black  color  of  the  feces,  followed  by  dark  urine,  both  appearing 
before  there  was  any  demonstrable  tumor  of  the  liver.  Fever  of  an 
intermittent  type  is  not  unusual  during  the  course  of  the  disease.  In 
most  cases  this  course  is  very  rapid  toward  a  fatal  termination. 

The  treatment  usually  must  consist  merely  in  palKation  of  the 
symptoms  as  they  develop.  Early  exploratory  laparotomy  may  serve 
to  clear  up  the  diagnosis,  and  in  some  cases  the  tumors  have  been 
excised  with  at  least  temporary  benefit  to  the  patients.  Knott,  in 
his  study  of  primary  hepatic  sarcoma,  referred  to  above,  found  that 
operation  had  been  done  in  twenty-seven  cases  with  fifteen  deaths, 
a  mortality  of  55.5  per  cent. 

In  eighteen  cases  the  tumor  was  excised;  eight  patignts  died, 
a  mortahty  of  44.4  per  cent.  In  six  cases  the  tumor  was  inoperable; 
four  patients  died,  a  mortality  of  66.6  per  cent.  In  three  cases  the 
nature  and  result  of  the  operation  are  not  recorded. 

Of  the  twelve  patients  who  survived  the  operation  for  any  length 
of  time,  the  after  history  is  known  in  only  six  cases:  three  of  these 
patients  died  in  less  than  four  months;  one  had  recurrence  after  seven 
months;  one  died  at  the  end  of  nine  months;  and  only  one  (Bardeleben) 
remained  in  good  health  for  as  long  a  period  as  two  years. 

Hemangeio-endothelio-sarcoma  of  the  Uver,  of  which  10  cases 
have  been  collected  by  Foote  (1919),  is  a  congenital  disease  manifest- 
ing itself  within  3  months  of  birth  by  enlargement  of  the  liver  and 
digestive  disturbances.  Usually  there  is  no  jaundice,  no  ascites,  and 
no  metastasis,  but  death  occurs  before  the  sixth  month  from  compression 
of  the  liver  tissue  by  the  growing  tumor. 


CARCINOMA    OF    LIVER  579 

Carcinoma  is  relatively  the  most  frequent  neoplasm  of  the  liver. 
It  occurs  in  middle  and  advanced  life'  and  is  seen  more  frequently  in  men 
than  in  women.  It  may  be  either  primary  or  secondary,  the  latter 
occurring  in  about  96  per  cent,  of  the  case?.  Among  10,000  autopsies, 
Hale  White  (1908)  found  ten  primary  tumors  and  240  secondary  to 
carcinoma  elsewhere.  Secondary  carcinoma  is  of  interest  from  the 
diagnostic  standpoint  alone,  as  it  is  not  amenable  to  surgical  treatment. 
Primary  carcinoma  may  be  removed  with  success,-  if  the  diagnosis  is 
made  early  enough ;  but  the  senior  author,  in  more  than  2000  laparotomies 
for  disease  of  the  liver  and  biliary  system  has  found  no  case  where  the 
primary  carcinoma  was  at  a  stage  where  cure  by  radical  operation 
might  have  been  hoped  for. 

Pathology. — Carcinoma  of  the  liver  occurs  in  three  forms: 

1.  Massive  carcinoma  appears  as  a  whitish  or  grayish  opaque 
mass,  may  grow  to  immense  size  (5-12  kg.)  and  usually  involves  the 
whole  of  a  lobe,  in  most  cases  the  right.  The  growth  is  well  defined 
from  the  surrounding  hepatic  tissue,  does  not  project  markedly  from 
the  surface,  and  the  general  form  of  the  liver  is  preserved  in  spite  of  the 
enlargement  If  a  tumor  of  this  kind  is  found  in  the  liver  it  is  useless 
to  search  for  a  primary  growth  elsewhere  (Langenbuch,  1897),  as 
the  hepatic  lesion  almost  surely  is  the  primary  tumor. 

2.  Infiltrating  or  diffuse  carcinoma  is  very  rare,  and  like  the  massive 
carcinoma  usually  is  a  primary  growth.  It  gives  no  metastases  (Lan- 
genbuch) and  histologically  often  is  mistaken  for  portal  cirrhosis  (page 
553)  or  nodular  adenomatous  hyperplasia  (page  574).  The  whole 
liver  is  affected  but  its  form  is  httle  altered  except  for  the  increase 
in  all  dimensions.  Its  surface  is  studded  with  little  smooth  round 
knobs,  the  size  of  peas  or  cherries,  and  between  them  the  hver  tissue 
is  shrunken  and  retracted.  According  to  some  authorities  (Fetzer 
and  Perls)  this  is  merely  the  most  advanced  form  of  the  massive 
carcinoma  already  described. 

3.  Nodular  or  multiple  carcinoma  is  the  usual  secondary  type 
and  is  also  the  most  frequent  primary  type.  Under  the  latter  circum- 
stances most  of  the  nodules  are  regarded  as  metastases  from  one  original 
primary  hepatic  tumor.  The  nodules,  which  are  scattered  irregularly 
over  the  surface  of  the  organ  especially  at  its  periphery,  are  whitish, 
gray  or  yellowish  masses  from  the  size  of  a  pin-head  to  that  of  an  orange, 
though  rarely  larger  than  a  walnut.  They  stand  out  from  the  surface 
of  the  liver;  frequently  cause  perihepatitis,  with  resulting  adhesions; 

'  Griffith  (1918)  refers  to  56  cases  recorded  in  children. 

'Freeman's  patient,  operated  on  in  1904,  was  reported  still  in  good  health  in  1919. 


S8o  TUMORS    OF    LrV'ER,    GALL-BLADDER    AND    BILE-DUCTS 

and  when  large  often  become  umbilicated  as  the  result  of  interstitial 
hemorrhages. 

Beadles  (1896)  maintained  that  a  clinical  distinction  was  not  dif- 
ficult between  primary  and  secondary  carcinoma,  even  in  this  nodular 
form.  Secondary  nodules  are  scattered  all  over  the  liver,  vary  in 
number  and  size,  and  may  leave  little  normal  hepatic  tissue  visible, 
but  they  are  always  more  or  less  rounded  in  form,  and  are  distributed 
with  fair  uniformity,  not  massed  particularly  about  the  fossa  of  the  gall- 
bladder or  the  quadrate  lobe.  '^Primary  malignant  disease  forms  a  hard, 
uniform  scirrhous  mass,  if  not  involving  at  least  close  upon  the  superior 
wall  of  the  gall-bladder."  It  spreads  backward  from  this  region  in 
the  tongue-like  prolongations  which  extend  beyond  the  general  mass. 
This  localization  is  characteristic,  and  serves  to  distinguish  primary 
from  secondary  carcinoma,  even  when  in  cases  of  the  former  nature 
there  are  metastases  from  the  original  tumor  in  other  parts  of  the  liver. 
The  main  feature  by  which  primary  may  be  differentiated  from  secondary 
carcinoma,  according  to  Beadles,  is  the  apparent  origin  of  the  former 
from  the  region  of  the  cystic  duct  or  neck  of  the  gall-bladder  or  the 
liver  tissue  immediately  adjoining.  Gall-stones  were  present  in  eleven 
out  of  thirteen  cases  of  primary  carcinoma  of  the  liver;  but  they  were 
found  only  in  two  of  sixty-three  cases  of  secondary  carcinoma. 

Primary  carcinona  of  the  liver  is  sUghtly  more  frequent  in  men  than 
in  women;  but  in  women  secondary  carcinoma  occurs  more  than  twice 
as  frequently  as  in  men  chiefly  owing  to  the  greater  frequency  of  primary 
growths  in  the  area  drained  by  the  portal  vein.  More  than  half  the 
cases  occur  between  the  ages  of  forty  and  sucty  years,  but  it  is  not 
an  excessively  rare  affection  even  in  childhood.  In  infants  and  young 
children,  however,  the  disease  usually  is  primary  in  the  Uver. 

The  symptoms  of  carcinoma  of  the  liver,  whether  primary  or  secon- 
dary, are  not  constant.  Probably  the  condition  is  diagnosed  during 
life  in  not  more  than  two-thirds  of  the  cases.  In  cases  of  secondary 
carcinoma  it  is  not  unusual  for  the  symptoms  referable  to  the  liver  to 
overshadow  those  caused  by  the  primary  growth.  Anore.xia,  gradual 
but  progressive  failure  of  strength  and  loss  in  weight,  and  vague 
digestive  disturbances  are  the  most  characteristic  sjonptoms;  but  the 
diagnosis  must  be  made  by  exploratory  laparotomy  unless  a  palpable 
tumor  has  developed. 

Cachexia,  which  develops  early,  usually  advances  steadily.  This 
is  especially  true  of  the  development  of  secondary  growths  in  the  liver, 
the  primary  growth  from  which  metastasis  has  occurred  very  fre- 
quently not  causing  any  cachexia  at  all. 


I 


CARCINOMA    OF    LIVER  58 1 

Jaundice  is  present  in  about  50  per  cent,  of  all  cases.  It  varies 
in  degree,  especially  at  first,  but  usually  increases  in  intensity  when 
present  and  persists.  It  may  be  due  to  obstruction  of  the  common 
duct  by  the  pressure  of  a  primary  growth  in  the  head  of  the  pancreas; 
to  secondary  nodules  in  the  lymph-nodes  along  the  common  duct; 
to  primary  foci  of  carcinoma  in  the  biliary  ducts;  or  to  direct  pressure 
on  the  intrahepatic  ducts. 

Pain  may  be  absent  in  carcinoma  of  the  liver,  but  there  always 
is  a  general  feeling  of  discomfort,  a  sense  of  weight  and  heaviness. 
The  actual  pain  varies  somewhat  with  the  position  and  extent  of 
the  growth.  When  the  neoplasm  is  deep  seated  there  is  not  very 
much  actual  pain;  when  the  capsule  of  the  liver  is  involved,  the  pain 
may  be  sharp  and  cutting  in  character.  With  the  formation  of  peri- 
hepatic adhesions,  pain  becomes  more  constant,  often  radiating  to 
the  epigstrium,  the  thorax,  the  back,  or  the  shoulder,  and  being  ag- 
gravated by  motion.  Colicky  pain  is  present  at  times  in  those  cases 
where  the  new  growth  is  near  the  hilum;  it  is  due  to  bihary  obstruction. 

Tenderness  may  be  elicited  on  deep  palpation,  but  it  is  not  present 
in  all  cases. 

Ascites  is  present  in  about  one-half  the  cases.  If  jaundice  is 
present  the  fluid  usually  is  bile  stained;  otherwise  it  is  clear.  Usu- 
ally it  is  not  excessive  in  amount,  and  but  little  discomfort  is  experi- 
enced from  its  presence.     Tapping  seldom  is  required. 

Enlargement  of  the  liver  is  the  most  constant  phenomenon,  the 
increase  in  size  at  times  being  very  great.  The  right  lobe  generally 
enlarges  more  than  the  left.  The  edges  may  be  palpable,  firm,  and 
hard,  but  usually  are  irregular  and  more  or  less  nodular. 

The  diagnosis  often  is  very  difficult  to  make,  unless  the  cases 
are  well  advanced,  or  unless  a  primary  focus  is  recognized.  In  some 
instances  an  exploratory  operation  may  be  advisable  to  clear  up  the 
diagnosis.  The  condition  must  be  difterentiated  especially  from 
abscess  or  echinococcus  cyst  of  the  liver,  syphilis  of  the  liver,  and 
biliary  hypertrophic  cirrhosis;  this  usually  may  be  done  by  careful 
study  of  the  history  and  by  the  physical  examination.  At  times 
it  is  impossible  to  differentiate  between  carcinoma  of  the  liver  and 
tumors  in  adjacent  structures,  such  as  the  stomach,  the  colon,  the 
kidney  or  the  omentum.  In  these  cases  exploratory  laparotomy  is 
justifiable. 

The  prognosis  is  practically  hopeless.  Hale  White  gave  the 
duration  of  life  as  four  months  after  the  development  of  symptoms 
in  primary  carcinoma  and  seven  months  after  the  symptoms  of  second- 


582  TUMORS    OF    LrV^ER,    GALL-BLADDER   AND   BILE-DLtctS 

ary  carcinoma  began.  If  a  primary  growth  can  be  completely 
removed  by  excision,  the  chances  of  permanent  cure  are  reasonably 
good;  but  there  are  exceedingly  few  cases  in  which  this  treatment 
is  possible.  Liicke's  patient  (1891)  according  to  Terrier  and  Auvray 
(1898)  died  of  recurrence  two  years  after  operation  (Yeomans  gives 
the  period  of  survival  as  eight  years).  Freeman's  (1904)  was  in 
good  health  fifteen  years  after  operation;  and  Schrader's  (1897)  re- 
mained in  good  health  seven  years  after  operation.  Hochenegg  's  patient 
survived  three  years,  and  for  two  years  of  this  time  was  in  good 
health  (Anschiitz,  1903). 

The  treatment  hitherto  has  been  considered  purely  palliative. 
This  certainly  still  is  true  of  secondary  carcinoma  where  operation 
is  contraindicated,  but  in  the  future  it  is  more  than  hkely  that  earlier 
exploratory  operation  will  reveal  an  increasing  number  of  cases  of 
primary  carcinoma  suitable  for  extirpation.  Operation  always  is 
contraindicated  in  the  presence  of  multiple  nodules,  marked  cholemia, 
advanced  cachexia,  and  lymphatic  enlargements.  When  the  tumor 
is  single,  of  primary  origin,  and  can  be  readily  reached,  partial  hepatec- 
tomy  may  be  performed.  Mayo  Robson  reports  having  exposed  the 
liver  by  operation  in  thirty-five  cases  and  finding  three  among  them 
which  he  considered  suitable  for  hepatectomy.  One  patient  died 
on  the  table,  and  the  other  two  died  from  recurrence  in  a  few  months. 
Terrier  and  Auvray  (1898)  collected  thirty-eight  radical  operations 
for  various  neoplasms  of  the  liver;  thirty-two  patients  recovered, 
and    six    died    from   the  operation,   giving  an  operative   mortality  of 

15.8  per  cent.  The  immediate  result  is  known  in  seventy-four  out  of 
seventy-five  cases  of  partial  hepatectomy  for  various  causes  tabu- 
lated by  Keen  (1899):  eleven  patients  died,  an  operative  mortality  of 

14.9  per  cent.  The  immediate  death  rate  following  operation  is 
largely  independent  of  the  nature  of  the  growth.  Yeomans  (1909) 
collected  ten  operations  for  primary  carcinoma  of  the  liver,  includ- 
ing a  case  of  his  own.  The  following  list  includes  also  an  operation 
by  Terrier,  which  Yeomans  seems  to  have  overlooked. 

(i)  Jacobs:  Thermocautery  and  drainage;  recovery;  recurrence  in  seven  months. 

(2)  Lapointe  (Operation  by  Segond):  Pedicle  clamped  and  divided;  death  on 
third  day. 

(3)  Lucke:  Elastic  ligature  and  cautery;  death  two  years  later  from  recurrence; 
(possibly  a  gumma). 

(4)  FiLiPPixi:  Elastic  ligature,  resection  two  days  later;  recurrence  and  death 
in  two  months. 

(s)  Keex:  Thermocautery  of    entire  left   lobe;   recurrence  and  death   in   five 
months. 


CARCINOMA    OF    GALL-BLADDER  583 

(6)  HocHENEGG:  Excised,  and  stump  fixed  in  abdominal  wound;  patient  died  of 
recurrence  three  years  later;  diagnosis  doubtful. 

(7)  L.  Freeman:  Tumor  isolated  by  gauze  strips  through  liver  substance;  opera- 
tion January  20,  1903;  excellent  health  1910.' 

(8)  Schrader:  Excised,    wound    cauterized    and    fixed    in    abdominal    wound; 
patient  alive  and  well  seven  years  after  operation. 

(9)  Roux:  Excised,  bleeding  controlled  by  suture  through  liver;  recovery. 

(10)  Yeomans:  Incised,  curetted,  packed  and  drained;  well  two   months  after 
operation. 

(11)  Terrier:  excision;  recovered,  but  three  months  after  operation  probably  had 
pelvic  recurrence. 

Tumors  of  the  Gall-bladder  anb  Bile-ducts 

Cystic  Degeneration  of  the  Gall-bladder. — This  is  a  rare  condition 
which  was  studied  carefully  by  Konjetzni  (191 1).  Licini  (191 1) 
has  published  another  case,  in  which  the  gall-bladder  was  converted 
into  a  multicystic  tumor  the  size  of  an  average  apple;  there  was  also  an 
adenocarcinoma  of  the  cystic  duct;  and  the  pressure  of  the  enlarged 
gall-bladder  on  the  common  duct  caused  jaundice  to  develop. 

According  to  Aschoff  and  Bacmeister  (1909)  there  is  in  about  3  per 
cent,  of  gall-bladders  an  adenomatous  structure,  especially  at  the 
fundus;  and  in  cases  of  infection  which  closes  these  glands,  cystic 
degeneration  may  occur.  They  believe  it  predisposes  to  the  develop- 
ment of  carcinoma. 

The  proper  treatment  is  cholecystectomy. 

Sarcoma  of  the  Gall-bladder. — Jaffe  (1920)  has  collected  12  cases, 
including  one  of  his  own,  of  primary  sarcoma  of  the  gall-bladder. 
In  Jaffe's  patient  there  had  been  symptoms  of  gall-bladder  disease  for 
two  months  before  operation.  In  none  of  the  reported  cases  did  the 
patients  recover  permanently. 

Carcinoma  of  the  gall-bladder  and  bile-ducts  is  much  more  common 
than  carcinoma  of  the  liver.  Secdarony  carcinoma  occurs  but  is  of  no 
surgical  interest  as  the  lesions  rarely  develop  except  late  in  a  general 
carcinomatosis. 

Primary  carcinoma  of  the  gall-bladder  and  bile-duels  is  much  more 
common  than  formerly  suspected.  It  is  found  in  about  5  per  cent,  of  all 
cases  of  carcinoma.  It  occurs  three  to  four  times  as  often  in  the  gall- 
bladder as  in  the  bile-ducts.  Musser,  in  1889,  was  able  to  collect  100 
cases,  in  sixty-four  of  which  the  variety  of  the  new  growth  was  clearly 
indicated.     Among  3908  operations  on  the  gall-bladder  and  biliary 

'  In  another  case   (carcinoma)  Freeman   used  strips  of  fascia  lata,  as  indicated  in 
Fig.  igo  (p.  794.) 


584  TUMORS    OF    LIVER,    GALL-B LADDER    AND    BILE-DUCTS 

passages,  performed  between  iSqo  and  1910,  W.  J.  Mayo  found  85 
cases  or  2.1  per  cent,  of  malignancy.  Erdmann  (1919)  found  15  in- 
stances of  malignancy  in  224  gall-bladder  operations  (6.7  per  cent.), 
and  in  one  series  of  68  operations  on  the  gall-bladder  reports  encounter- 
ing no  less  than  9  cases  of  carcinoma.  The  senior  author  found  2.3  per 
cent,  of  mahgnance  in  262  operations  performed  by  him  at  the  German 
Hospital  but  in  another  series  of  820  gall-bladders  submitted  (1916- 
1920)  for  pathological  examination,  only  six  (0.73  per  cent.)  were 
reported  as  being  carcinomatous. 

Primary  carcinoma  of  the  gall-bladder  is  most  frequently  seen 
between  the  ages  of  fifty  and  sixty  years;  but  Proscher  reported  a 
case  in  a  man  twenty-two  years  of  age.  It  is  much  more  frequent 
in  women  than  in  men,  the  proportion  being  3-1  according  to  Musser 
(1889),  and  4~i  according  to  Fiitterer  (1901).  Among  seven  patients 
operated  upon  by  the  senior  author,  six  were  women  varying  in  age 
from  thirty-six  to  sixty-three;  the  seventh  patient  was  a  male,  twenty- 
six  years  old.  Another  patient  whose  gall-bladder  is  represented  in 
Plate  Vm,  was  70  years  of  age. 

Schroder  (1892)  said  that  14  per  cent,  of  all  gall-stone  patients  even- 
tually suffer  from  carcinoma  of  the  biliary  apparatus.  The  theory 
that  the  irritation  of  the  gall-stones  predisposes  to  the  development  of 
carcinoma  in  the  gall-bladder  is  well  borne  out  by  statistics:  thus 
Musser  found  gall-stones  associated  with  carcinoma  in  69  per  cent,  of 
the  cases;  Fiitterer,  in  78  per  cent.;  Winton,  in  81  per  cent.;  Zenker,  in 
91  per  cent.;  Courvoisier,  in  91  per  cent.;  Siegert,  in  95  per  cent,  and 
Janowski,  in  100  per  cent.  In  the  senior  author's  series,  gall-stones 
were  present  in  87  per  cent.  The  theory  of  irritation  as  a-causative  factor 
in  producing  carcinoma  of  the  gall-bladder  is  supported  by  the  fact 
that  Beadles  (1896),  in  a  study  of  twenty-eight  personal  cases  of  sec- 
ondary carcinoma  of  the  liver  and  gall-bladder,  did  not  find  gall-stones 
in  a  single  instance;  while  in  a  total  of  sixty-three  cases  of  secondary 
carcinoma  gall-stones  were  present  in  only  two  instances. 

PaUwlogy. — Primary  carcinoma  of  the  gall-bladder  is  most  fre- 
quently found  in  the  fundus,  the  secondary  site  of  preference  being  near 
the  neck  of  the  bladder  or  the  beginning  of  the  cystic  duct.  In  other 
cases  the  entire  organ  may  be  involved.  In  his  analysis  of  forty-five 
cases,  Fiitterer  found  the  growth  in  the  fundus  in  seventeen,  near  the 
opening  of  the  cystic  duct  in  thirteen,  on  the  posterior  wall  in  eight, 
and  on  the  anterior  wall  in  seven. 

Most  cases  are  of  the  columnar-cell  type;  but  Konjetzni  (1911) 
collected  twenty-three  instances  of  squamous-cell  carcinoma  of  the 
gall-bladder. 


Plate  VIII 


Ml 

O    4J 


cU 
CD 


K 


2  >< 
■t^  o 


o    oj 


0^ 


1^1 

Cll      OJ      ^ 

O  XI  -^ 


CARCINOMA    OF    GALL-BLADDER  585 

There  are  two  types  of  new  growth  recognized,  although  in  any 
case  the)^  may  coexist.  In  one  there  is  a  cauhflower-Hke  growth 
which  projects  into  the  cavity  of  the  gall-bladder;  in  the  second  form 
there  is  a  general  infiltration  of  the  walls  of  the  organ.  Although  the 
growths  usually  are  circumscribed  in  the  beginning,  infiltration  becomes 
marked  and  nodular  enlargement  of  the  gall-bladder  results.  If  the 
cystic  duct  is  obstructed,  the  gall-bladder  usually  becomes  distended; 
the  contents  usually  are  bloody.  Perforation  into  the  general  peri- 
toneal cavity  rarely  ensues,  although  adhesions  to  the  surrounding 
viscera  are  common;  in  this  way  stenosis  of  the  duodenum,  pylorus,  or 
colon,  may  occur.  In  some  cases  ulceration  into  the  colon,  stomach  or 
duodenum  with  the  formation  of  an  internal  biliary  fistula  may  result. 
An  external  biliary  fistula  is  very  rare,  except  as  the  result  of  operation. 
Extension  to  the  liver  is  found  in  about  50  per  cent,  of  the  cases,  the 
processes  in  the  liver  being  the  result  of  direct  extension  along  the 
biliary  ducts  or  by  the  lymphatics.  As  noted  at  page  580,  Beadles 
inclines  to  the  view  that  most  if  not  all  cases  of  primary  carcinoma  of 
the  liver  arise  at  or  near  the  cystic  duct  or  neck  of  the  gall-bladder. 

Carcinoma  of  Gall-bladder;  Cholecystectomy;  Recurrence 

M.  S.,  53  years  old,  married  27  years,  was  admitted  to  the  German  Hospital 
December  16,  1906. 

Chief  Complaint. — Feeling  of  distress  in  gall-bladder  region. 

Family  History. — Father,  mother,  three  sisters  and  one  brother  living  and  well. 
One  sister  died  of  pulmonary  tuberculosis.  Several  brothers  and  sisters  died  in 
infancy.     No  mahgnancy. 

Social  History. — Two  children  living  and  well.  Youngest  is  sixteen  years  old. 
Had  one  miscarriage  between  two  living  children.  Forceps  dehvery  for  both 
children.     One   child   born   dead.     One   died   of  diphtheria   eighteen   years   ago. 

Previous  Medical  History. — Measles  in  childhood;  otherwise  negative.  Appetite 
good  and  bowels  regular  before  present  illness. 

Present  Illness. — Has  slowly  developed  a  feeling  of  distress  in  the  gall-bladder 
region  with  loss  of  appetite,  weight  and  ambition.  Gradually  lost  about  fifteen 
pounds.  No  acute  attacks  of  pain.  Never  vomited  blood.  Jaundice  of  gradual 
onset. 

Operation. — December  18,  1906,  by  Dr.  Deaver.  Right  rectus  incision.  Liver 
raised,  and  gall-bladder  exposed.  Field  of  operation  walled  off  with  gauze.  The 
gall-bladder  was  surrounded  almost  completely  by  omental  adhesions,  which  could 
be  stripped  off  easily  with  gauze.  The  gall-bladder  was  enlarged,  distended  and 
full  of  stones  of  various  sizes.  The  neck  of  the  gall-bladder  just  above  the  cystic 
duct  was  folded  so  as  to  form  a  small  sac  pressing  upon  the  duct.  Cholecystectomy 
decided  upon:  gastro-hepatic  omentum  grasped  and  opened;  cystic  duct  clamped 
and  cut,  and  cystic  vessels  clamped  and  cut.     Gall-bladder  pulled  free  from  liver 


586  TUMORS    OF    LIVER,    GALL-BLADDER   AND   BILE-DUCTS 

and  removed.  Cystic  duct  tied  with  chromic  catgut,  and  cystic  vessels  with  linen 
thread.  One  cigarette  drain  placed  about  cystic  duct,  and  sewed  fast  with  chromic 
gut.  Several  bleeding  points  in  bed  of  gall-bladder  clamped  and  tied  with  catgut. 
A  piece  of  plain  gauze  rolled  and  placed  in  bed  of  gall-bladder  to  control  hemorrhage, 
and  held  in  place  by  catgut  stitch.  Pads  and  sponges  removed,  \iscera  replaced. 
Wound  closed  in  layers.     (Fig.  155. 

Progress. — Persistent  jaundice  after  operation,  relieved  greatly  after  removal  of 
second  piece  of  gauze  (Dec.  31,  1906),  which  had  to  be  pulled  very  hard. 

Discharged  from  the  hospital,  January  26,  1907. 

Re-admitted  to  the  German  Hospital,  April  i,  1907,  less  than  four  months  after 
operation.  Has  continued  to  complain  of  weakness  since  leaving  the  hospital. 
Went  home  in  a  carriage  and  has  been  in  bed  ever  since.  Has  had  pain  in  the  light 
side,  with  nausea  and  vomiting.  A  few  weeks  ago  she  could  not  keep  anything 
on  her  stomach.  Has  had  sweats  with  remittent  and  intermittent  temperature. 
Has  lost  weight,  but  does  not  know  how  much.  Has  hved  on  liquid  diet  ever  since 
leaving  the  hospital. 


Pig.    155. — Gall-bladder  Removed  by  Cholecystectomy.     Found  on  Microscopical  Exam- 
ination to  be  Carcinomatous.     (Case  of  M.  S.,  page  585.) 

Physical  Examination. — "Lemon  colored"  complexion.  No  distinct  jaundice. 
Heart  and  lungs  negative. 

Abdomen:  Old  scar  and  stab-wound  from  gall-bladder  operation.  Line  of 
induration  readily  felt  along  line  of  drainage.  Lower  border  of  liver  palpable  down 
almost  to  the  umbilicus.  Upper  border  of  absolute  dullness  about  fifth  interspace. 
Spleen  not  palpable  or  demonstrably  enlarged. 

Progress. — Gradual  loss  of  weight,  health  and  strength.  At  time  of  discharge 
from  hospital  May  14,  1907,  the  drainage  tract  had  increased  greatly  in  size  and 
was  very  hard,  adherent  to  skin. 

Urine. — Shows  albumin. 

Stool. — Free  fat,  bile  and  occult  blood  negative. 

Blood. — Hb.,  54  per  cent.,  W.  B.  C,  10,7000. 

Differential  Count. — Polys.,  82.5  per  cent.;  lymph.,  13;  Trans.,  4;  Mon.,  o; 
eosin.,  o;  mast.,  0.5. 

April  25,  1907:  Hb.,  45  per  cent.,  W.  B.  C,  10,900. 

The  following  case  history  shows  the  possibility  of  inflammation 
and  irritation  other  than  that  caused  by  calculi  acting  as  an  etiological 
factor  in  gall-bladder  carcinoma. 


CARCINOMA    OF    GALL-BLADDER  587 

A.  F.,  female.,  forty-nine  years  of  age  was  admitted  to  the  German  Hospital 
in  January,  1907. 

Family  history,  negative.     No  tuberculosis  or  malignancy. 

Previous  History .—Yizs  had  seven  children.  Thirteen  years  ago  had  an  attaclc 
of  acute  nephritis;  four  years  ago  an  attack  of  pneumonia;  one  year  ago  an  attack  of 
acute  appendicitis  at  which  time  there  was  marked  pain  in  the  upper  right  quadrant 
of  the  abdomen,  and  patient  was  jaundiced.  Chief  complaint  on  admission  to 
hospital  was  profuse,  foul-smelling,  at  times  bloody,  vaginal  discharge. 

Physical  examination:  large,  stout,  well-nourished  woman,  with  flabby,  pendu- 
lous abdomen.  No  pain  or  tenderness  over  entire  abdomen.  Vaginal  examination 
revealed  presence  of  a  small,  freely  movable  uterus  with  normal  appendages. 
A  small  polyp  was  protruding  from  cervix.  Two  days  after  admission  patient  was 
suddenly  seized  with  pain  over  gall-bladder  region  followed  by  rise  of  temperature, 
marked  tenderness  and  rigidity  over  the  gall-bladder  and  shght  jaundice.  Patient 
rapidly  recovered  from  the  gall-bladder  attack. 

Operation:  March  30,  1907. — The  uterus  was  curetted.  Pathological  examina- 
tion showed  absence  of  any  malignance.  Upper  right  rectus  incision  made. 
Adhesions  of  some  standing  between  the  gall-bladder  and  stomach  and  duodenum; 
new  adhesions  between  gall-bladder  and  Uver.  Adhesions  ligated  and  cut  and 
gall-bladder  freed.  Gall-bladder  aspirated  and  reddish-brown  bile  removed. 
Gall-bladder  opened.  No  gall-stones  found.  Cystic  and  common  ducts  patulous. 
Mucous  membrane  swollen  and  congested.  Cholecystostomy  with  protective 
gauze  and  rubber-dam  drainage. 

Stihsequent  Course. — Patient  made  a  good  recovery.  Was  relieved  of  all  trouble 
until  the  summer  of  igoS,  when  she  complained  of  a  dull,  aching  pain  about  the 
incision.  Pain  was  more  or  less  constant,  with  sharp  exacerbations.  Has  been 
nauseated  with  vomiting.  During  and  after  very  sharp  pains  would  become  jaun- 
diced.    Readmitted  to  the  German  Hospital,  July  17,  1909. 

No  jaundice.  Great  rolls  of  fat  on  pendulous  abdomen.  Sense  of  a  mass  near 
old  scar.     Tenderness  on  palpation. 

Second  Operation,  July,  1909. — Upper  right  rectus  incision.  Gall-bladder  region 
found  to  be  a  dense  mass  of  tissue,  evidently  carcinoma.  Numerous  carcinomatous 
nodules  on  lesser  omentum  and  about  gall-bladder  site.  Nodule  removed.  Wound 
drained  and  closed  to  drainage.  Pathological  report  of  nodule  proved  it  to  be 
carcinoma. 

Patient  made  an  operative  recovery  and  was  discharged  from  the  Hospital 
August  6,  1909.     Subsequent  history  not  known. 

Symptoms. — These  are  much  the  same  as  those  of  primary  carcinoma 
of  the  liver,  especially  when  the  tumor  arises  in  the  mucous  membrane 
of  the  gall-bladder;  the  carcinoma  that  arises  from  the  glands  of  the 
gall-bladder's  mucous  membrane  is  more  apt  to  produce  symptoms 
referable  to  the  gall-bladder  itself  or  its' ducts.  In  the  vast  majority 
of  cases  the  patient  who  presents  a  hard  nodular  tumor  of  the  gall- 
bladder or  liver  which  may  be  diagnosticated  certainly  as  carcinoma, 
without  an  exploratory  operation,  is  already  beyond  the  help  of 
surgery. 


588  TUMORS    OF    LIVER.    GALL-BLADDER    AND    BILE-DUCTS 

Treatment. — The  most  favorable  cases  are  those  where  a  thick- 
walled  gall-bladder  removed  at  operation  is  recognizably  affected 
by  carcinoma  only  after  microscopical  study.  Most  cases  recognized  as 
malignant  during  the  operation  prove  to  be  too  far  advanced  for  excision 
to  be  justitiable;  or  if  excision  is  done,  the  patients  die  of  recurrence 
within  a  year.  On  the  other  hand,  among  seven  cases  recognized 
as  carcinomatous  only  after  microscopical  study,  Mayo  had  three 
patients  who  were  well  more  than  two  years  after  operation.  But 
whenever  possible,  even  in  cases  recognized  as  malignant,  excision  of  the 
gall-bladder,  cystic  duct  and  of  the  adherent  surface  of  the  liver,  should 
be  done.  Palliative  operation  is  of  little  use  in  relieving  the  most 
distressing  symptoms,  and  in  most  cases  merely  entails  upon  the  patient 
the  additional  discomfort  of  a  biliary  or  mucous  fistula.  If  a  radical 
operation  cannot  be  done,  the  abdomen  should  be  closed  without 
doing  anything  else.  Terrier  and  Auvray  (iqoi)  collected  sixteen 
cholecystectomies  for  carcinoma  of  the  gall-bladder,  recognized  as 
such  at  operation;  there  were  five  deaths  (an  immediate  mortality  of 
31  per  cent.)  and  eleven  rapid  recurrences.  Among  eighteen  opera- 
tions where  a  portion  of  the  liver  was  removed  along  with  the  gall- 
bladder, there  were  three  immediate  deaths  (16.6  per  cent.)  and  four- 
teen deaths  from  recurrence  in  from  six  to  eight  months.  One  patient 
(that  of  Hochenegg,  already  referred  to  at  page  583)  survived  for  three 
years,  during  two  years  of  which  time  he  enjoyed  good  health.  These 
more  radical  operations  had  all  been  done  since  1890.  Terrier  and 
Auvray  came  to  the  pessimistic  conclusion  that  while  the  end  results 
of  radical  operation  for  this  condition  were  detestable,  yet  those  of 
palliative  operation  were  still  more  detestable.  They  found  among 
fifteen  cholecystomies  in  cases  of  malignant  disease,  that  four  patients 
died  from  operation,  and  only  one  survived  as  long  as  a  year.  Pal- 
liative operation  should  be  done  only  for  signs  of  grave  cholecystitis 
or  cholangeitis. 

Primaiy  Carcinoma  of  the  Bile-ducts. — This  occurs  in  men,  in 
about  61  per  cent,  of  cases;  thus  showing  a  marked  contrast  to 
carcinoma  of  the  gall-bladder,  which  occurs  in  men  in  only  about 
20  or  15  per  cent,  of  cases.  In  an  analysis  of  sixty  cases  of  carcinoma 
of  the  biliary  ducts.  Schiiller  (1901)  found  forty-one  at  the  papilla  of 
Vater,  and  nineteen  in  the  common  duct  or  the  hepaticus.  Rolleston 
found  the  growth  situated  as  follows  in  eighty  cases:  In  the  common 
bile-duct,  thirty- three  (lower  end  twenty-one,  mid-part,  eleven);  at 
the  junction  of  the  common  bile-duct,  cystic  duct  and  common  hepatic 
duct,  twenty-five;  in  the  common  hepatic  duct,  eighteen;  in  the  right 


CARCINOMA    OF   BILE-DUCTS  589 

or  left  hepatic  ducts,  three;  in  the  cystic  duct,  one;  and  in  the  cystic 
duct  and  lower  end  of  the  bile  duct,  one  (Kelly,  1908).  In  102  cases 
Donati  (1909)  found  twenty-nine  of  the  choledochus,  thirty-four  at 
the  hepatico-cystic  juncture,  twenty-eight  of  the  hepaticus,  one  of  the 
cysticus,  and  ten  not  located.  According  to  Lincini  (191 1)  his  case  of 
carcinoma  of  the  cystic  duct  was  the  third  on  record.  The  result  of  the 
growth  of  carcinoma  of  the  ducts  usually  is  a  constriction,  with  dilata- 
tion of  the  ducts  above  the  growth.  The  obstructing  tumor  occurs 
either  as  an  annular  growth  which  concentrically  constricts  the  duct,  or 
as  a  papillary  outgrowth  into  the  duct  lumen.  Wide  infiltration  of  the 
ducts  is  rare.  Carcinoma  at  the  papilla  of  Vater  may  be  of  i)2tes- 
tinal,  pancreatic,  or  biliary  origin.  Clinically  it  resembles  cylin- 
drical-celled carcinoma  of  other  portions  of  the  intestinal  tract  in 
its  slow  and  superficial  growth,  and  its  slight  tendency  to  metas- 
tasis (Terrier  and  Auvray).  Obstruction  in  the  common  duct 
results  in  distention  of  the  gall-bladder  unless  this  has  been  previ- 
ously diseased  and  contracted.  When  the  growth  is  in  the  hepatic 
duct,  the  gall-bladder  usually  is  small.  Enlargement  of  the  liver 
occurs  in  almost  all  cases,  and  there  may  also  be  associated  obstruction 
of  the  portal  circulation  and  the  development  of  ascites. 

Symptoms. — In  carcinoma  of  the  extra-hepatic  biliary  ducts  the 
symptoms  are  not  marked,  as  a  rule,  until  partial  obstruction  of  the 
duct  occurs.  As  in  all  conditions  affecting  the  bihary  tract,  symptoms 
of  dyspepsia  may  be  noted,  but  usually  the  first  symptom  that  calls 
attention  to  the  bihary  apparatus  is  the  onset  of  jaundice.  In  most 
cases  the  jaundice  develops  gradually,  although  rare  cases  may  show 
sudden  icterus  similar  to  calculus  obstruction.  The  jaundice  of 
carcinoma  of  the  duct  is  permanent  and  never  intermittent. 

Pain,  of  a  dull  aching  character,  may  be  noted  in  the  gall-blad- 
der region  or  in  the  epigastrium.  WJien  a  distended  gall-bladder 
attempts  to  empty  itself,  there  may  be  coHcky  pains  simulating  gall- 
stone colic. 

The  gall-bladder  usually  is  enlarged  on  account  of  the  obstruc- 
tion, below,  and  is  palpable  in  more  than  50  per  cent,  of  the  cases. 
The  fiver  is  slightly  enlarged. 

The  diagnosis  must  be  made  from  calculous  obstruction  of  the 
common  duct.  In  the  latter  cases,  the  jaundice  develops  suddenly, 
is  intense,  but  intermittent,  the  stools  are  not  constantly  acholic; 
in  carcinoma  it  develops  slowly,  steadily  increases  and  never  becomes 
intermittent,  no  bile  being  found  in  the  feces  at  any  time  after  complete 
obstruction  has  once  developed.     In  calculous  obstruction,  the  pain 


59°  TUMORS    OF    LWER,    GALL-BLADDER    AND   BILE-DUCTS 

is  sudden,  severe,  radiates  to  the  right  shoulder,  and  is  accompanied  by 
marked  tenderness  and  rigidity  in  the  region  of  the  gall-bladder;  in 
carcinoma  there  is  only  a  dragging  sensation,  often  attributed  to  gastric 
disorder.  In  calculous  obstruction  the  temperature  usually  is  elevated 
and  the  attack  may  be  ushered  in  by  a  chill;  in  carcinoma  there  rarely 
is  fever.  In  the  former  case  the  patient's  general  nutrition  may  be 
preserved  for  a  long  time,  and  the  patient's  appetite  and  digestion 
depend  on  the  intensity  of  the  colic  and  jaundice;  in  carcinoma,  on  the 
other  hand,  strength  is  quickly  lost,  signs  of  duodenal  obstruction 
supervene,  and  emaciation  is  rapid. 

An  enlarged  gall-bladder,  in  the  pressure  of  increasing  and  non- 
remitting  jaundice,  is  due  to  carcinoma  in  a  large  majority  of  cases; 
the  jaundice  due  to  common  duct  obstruction  is  accompanied  by 
a  contracted  gall-bladder  in  84  per  cent,  of  the  cases,  according  to 
Courvoisier  (1890).  Before  enlargement  of  the  gall-bladder  occurs 
diagnosis  is  very  difl&cult;  but  this  enlargement  develops  so  con- 
stantly as  soon  as  obstruction  is  complete,  that  there  is  little  excuse 
for  failure  to  recognize  the  true  lesion  after  the  development  of  jaun- 
dice. Disturbance  of  the  pancreatic  functions  indicated  a  growth 
at  the  papilla  of  Vater  or  a  carcinoma  of  the  pancreas  (page  691); 
distinction  is  difficult. 

Prognosis. — The  disease  is  fatal  unless  all  of  the  diseased  struc- 
tures can  be  removed  by  operative  means.  The  ultimate  outcome 
of  the  condition  is  greatly  modified  by  the  form  of  treatment  and  by 
the  stage  of  the  growth  when  operation  is  performed.  If  the  dis- 
eased structures  are  removed  early,  the  prognosis  is  fairly  favorable; 
if  the  growth  is  not  entirely  removed,  or  if  the  disease  is  so  far  ad- 
vanced as  to  be  inoperable,  death  usually  results  in  from  six  to  eight 
months. 

Treatment. — Prophylactic  treatment  should  be  instituted  in  all 
instances  by  removal  of  all  gall-stones  that  may  be  in  the  gall-bladder 
and  ducts  as  sopn  as  their  presence  has  been  determined.  The  treat- 
ment of  carcinoma  of  the  common  duct  is  either  palliative  or  radical, 
consisting  in  the  formation  of  a  fistula  between  the  gall-bladder  and 
the  gastro-intestinal  tract  or  in  a  resection  of  the  duct  with  removal 
of  the  growth.  Resection  of  the  duct  and  the  various  steps  necessar\' 
to  restore  a  channel  for  the  discharge  of  bile  into  the  intestinal  tract 
have  been  discussed  at  page  508. 

Removal  of  a  growth  from  the  papilla  of  Vater  or  from  the  duo- 
denal end  of  the  common  duct  may  be  accomplished  through  a  trans- 
duodenal incision,  as  first  employed  by  Czerny  in   1901    (Schiiller). 


CARCINOMA    OF   BILE -DUCTS  59I 

Oppenheimer  (191 2)  collected  eighteen  operations  of  this  kind;  tifteen 
of  the  operations  were  for  carcinoma  with  six  deaths;  one  for  benign 
tumor,  and  two  for  cicatricial  stricture,  all  three  successful. 

Upcott  also  recorded  (191 2)  a  successful  transduodenal  excision 
of  a  carcinoma  of  the  papilla  Vater;  the  patient  was  doing  well  one 
month  after  operation.  Outerbridge-  (1913),  in  his  careful  study  of 
this  subject,  notes  also  an  operation  (unsuccessful)  recorded  by  Slajner. 

In  cases  where  the  growth  was  too  extensive  for  transduodenal 
excision,  a  few  attempts  at  more  radical  excision  have  been  made 
(Halsted,  Korte,  Kausch).  The  operation  in  these  cases  was  simi- 
lar to  the  cephalic  pancreatectomy  of  Sauve  (page  795).  Halsted's 
patient  survived  for  six  months,  but  Korte's  patient  died  in  three 
days.  The  method  of  Cotte  and  Maurizot  is  described  at  p.  367. 
Kausch  (191 1)  advises  the  following  technique,  which  he  has  employed 
successfully,  though  his  patient  died  nine  months  later  of  cholangeitis: 

I.  Primary  operation.  Cholecystenterostomy,  as  a  temporarj'  means  to  restore 
the  patient's  health.  It  is  worth  noting,  however,  that  according  to  Quenu's 
figures  (quoted  in  our  first  edition)  seventeen  out  of  twenty-one  patients 
treated  by  this  operation  did  not  survive. 

II.  Extirpation  of  the  growth. 

1 .  Mobilization  of  the  duodenum. 

2.  Posterior  gastro-jejunostomy. 

3.  Section  and  closure  of  pylorus. 

4.  Enucleation  of  duodenum  and  adjacent  pancreas. 

5.  Section  of  choledochus  and  pancreatic  duct. 

6.  Duodenum  is  sectioned  below  the  growth,  and  its  distal  segment  is  sutured 
over  remains  of  pancreas,  the  intervening  segment  with  the  stump  of  the  common 
duct  and  the  pancreas  being  removed. 

7.  Choledocho-enterostomy. 

The  second  stage  of  Kausch's  operation,  as  described  above, 
required  four  hours  for  its  completion.  In  cases  where  the  carcinoma 
is  in  the  retroduodenal  portion  of  the  choledochus,  excision  of  the 
affected  portion  of  the  duct  may  be  attempted  after  mobiUzation  of 
the  duodenum.  Oppenheimer  collected  eighteen  such  operations,  ten 
of  which  were  for  carcinoma,  with  six  deaths;  three  for  calculous 
obstruction,  with  no  deaths;  four  for  benign  cicatricial  stricture,  with 
two  deaths;  and  one  fatal  operation  for  benign  tumor. 

After  excision  of  the  growth,  the  continuity  of  the  bile-tract  must 
be  restored  as  already  described  (page  508). 

Operations  in  the  presence  of  obstructive  jahndice  from  carcinoma 
may  prove  very  serious  undertakings  on  account  of  the  great  danger  from 


592  TUMORS    OF    LIVER,    GALL-BLADDER   AND   BILE-DUCTS 

hemorrhage.'  But  in  spite  of  the  lugubrious  statistics  pubUshed  in  the 
first  edition  of  this  work,  further  experience  has  convinced  us  that 
operation  is  justifiable  in  an}'  patient  in  whom  it  seems  possible  to 
aft'ord  rehef,  even  if  the  operation  is  only  a  palliative  one.  We  have 
had  a  number  of  patients  whose  last  days  were  rendered  tolerable  by 
relief  of  jaundice  and  of  much  pain,  as  the  result  of  cholecystenteroa- 
tomy  (p.  505). 

'  Quenu  recommends,  and  has  employed  since  1907,  the  prophylactic  use  of  anti- 
diphtheritic  serum,  which  is  the  most  easUy  procured  alien  serum.  He  injects  20  cc.  of  this 
on  the  day  before  the  operation,  and  since  using  this  precaution  has  had  only  one  case  of 
postoperative  hemorrhage  in  these  icteric  patients.  Other  measures  employed  as  prophy- 
laxis against  bleeding  have  been  discussed  at  page  436. 


CHAPTER  XX 
INJURIES  OF  THE  LIVER  AND  BILIARY  PASSAGES 

Injuries  of  the  Liver 

The  liver  is  more  often  injured  than  any  of  the  solid  abdominal 
viscera,  though  scarcely  so  often  as  the  intestinal  tract.  It  is  predis- 
posed to  injury  (i)  by  its  size,  especially  if  this  is  increased  by  disease; 
(2)  by  its  position  in  contact  with  the  anterior  abdominal  wall  and 
ribs  in  front,  with  the  vertebral  column  behind,  and  with  the  diaphragm 
above;  (3)  by  its  consistency,  being  naturally  inelastic,  and  having  its 
friability  increased  by  disease;  and  (4)  by  its  relative  immobility.  Not- 
able is  the  fact  that  83  per  cent,  of  sixty-five  patients  with  injury  of  the 
liver,  reported  by  Boljarski  (191 1),  had  been  drinking  or  were  actually 
intoxicated  when  they  received  their  injuries. 

In  a  series  of  365  cases  of  subcutaneous  injury  of  the  solid  abdominal 
viscera,  studied  by  Edler  (1887),  the  liver  was  injured  in  189  cases, 
while  the  pancreas,  spleen  and  kidneys,  all  combined,  were  injured 
only  in  176  instances.  Of  116  penetrating  wounds,  the  liver  was  in- 
volved in  sixty-five,  while  the  pancreas,  spleen  and  kidneys  combined 
were  involved  in  fifty-one  cases. 

Injuries  of  the  hver  may  be  classed  as  subcutaneous  (ruptures), 
and  percutaneous  (stab  and  gunshot  wounds).  The  relative  frequency 
of  ruptures  and  of  stab  and  gunshot  wounds  varies  considerably  with 
the  geographical  location  of  the  patients.  In  this  country  rupture  is 
the  most  frequent  form  of  injury,  and  this  appears  also  to  be  the  case  in 
Germany,  as  well  probably  as  in  Great  Britain  and  France.  But  in 
St.  Petersburg  Boljarski  found  ruptures  comparatively  rare. 


Relative  Frequency  or  Liver  Injuries 

Author 

Rupture 

Gunshot  wounds 

Stab  wounds 

Total 

Boljarski  (Russia)  (1911) 

Finsterer  (Germany)  (1912) 

Tilton  (New  York  City)  (1905). . 

8 
12 

2 
II 

9 

S5 
4 

4 

6S 
40 

2S 

38 


593 


each 


57 

cases. 

i8 

cases. 

i8 

cases. 

12 

cases. 

6 

cases. 

I 

case. 

594  INJUKIES    OF    THE    LI\'ER    .AND   BILIARY    P.^SSAGES 

Uncomplicated  injuries  of  the  liver  are  much  less  rare  than  are  un- 
complicated injuries  of  any  other  viscus  in  the  upper  abdomen.  Com- 
plicating injuries  oftenest  involve  the  pleura,  diaphragm  or  lung;  less 
often  the  kidneys,  stomach  or  pancreas.  Ruptures  are  much  more 
often  uncompHcated  than  are  gunshot  or  stab  wounds.  In  Boljarski's 
series  of  sixty-five  cases  there  were  the  following  complicating  injuries: 

Abdominal  wall 

Diaphragm 

Pleura. 

Ribs 

Stomach 

Bowels 
Mesentery 
Pancreas 
Spleen 

Prognosis. — The  mortality  recorded  in  most  statistics  is  too  low, 
since  it  is  deducted  from  collected  cases,  and  not  from  a  large  and 
consecutive  series.  Among  isolated  case  reports  favorable  results 
always  unduly  predominate.  The  following  classical  statistics  may  be 
perused  in  this  connection: 

Cases  of  Injury  of  the  Lu'er  (No  Operation) 

Mayer  (1872)  276  cases         5g  per  cent,  mortality. 

Otis  (1876).  iSi  cases         62  per  cent,  mortality. 

Edler  (1887).  .     104  cases         57  per  cent,  mortality. 

Edler  collected  in  all  54.3  cases  of  liver  injury,  treated  without 
operation:  189  ruptures,  with  162  deaths;  289  gun-shot  injuries, 
with  159  deaths;  and  65  stab  wounds,  with  42  deaths;  a  total  mor- 
tality of  66.8  per  cent. 

Operations  for  Injury  of  the  Liver 

Terrier  and  .\uv'ray  (1896) 56_  operations         32  .0  per  cent,  mortality. 

Terrier  and  Auvray  (1901 1  42  operations         23.6  per  cent,  mortality. 

Giordano  (1902') 257  operations         a  5  per  cent,  mortality. 

The  first  operation  for  hemorrhage  from  the  liver  was  done  in 
1887  by  Burckhardt,  in  a  case  of  stab  wound;  the  wound  was  packed 
and  the  patient  recovered. 

The  prognosis  of  the  three  main  varieties  of  liver  injury  is  indicated 
by  the  following  statistics: 


RUPTURE    OF    THE    LIVER  595 

Statistics  of  Operative  Treatment  of  Injuries  of  the  Liver 


Ruptures 

Gunshot  wounds 

Stab 

wounds 

Author 

O 

H 

S 

« 

■a 
Q 

u 

■a 

5 

11 

•a 
0 

Boljarski. . . 

8 

12 

IS' 
6= 

0 
3 
3 

4 

8 

9 

12 
2 

100. 0 

7SO 
80.0 

33 -o 

62.  s 
61. S 

2 

I 

I 

5° 

0 
i3 
49 

SS 
7 

2 

38 

17 
0 

40.0 

Hagen 

Wilms 

I 

I 

0 

Finsterer 

Tilton 

0.0 

28. s 
24.6 

Thole    (all   collected 
cases  to  igog). 

260 

100 

160 

200 

102 

98 

292 

2  20 

72 

The  great  importance  of  early  operation  is  indicated  by  the  following 
statistics  of  Thole: 


Mortality  After 

Operations  For  Injuries  of  the  Liver 

Rupture, 
mortality 
per  cent. 

Stab  wound,        Gunshot  wound, 
mortality                 mortality 
per  cent.         '         per  cent. 

1.  Operation  within  six  hours. . .  . 

2.  Operation     from     seven     to 

twelve  hours .    .  . 

395 

SO-4 
66.6 
86.3 

! 

14    5                                     32-2 
20    7                                     ,11;? 

3.  Operation    from    thirteen    to 

33-3 
50.0 

50-3 

7S-4 

4.  Operation    after    twenty-four 
hours 

Rupture  of  the  Liver. — The  causes  are  direct  and  indirect  violence 
Blows,  falls  and  crushes  are  the  usual  forms  of  direct  injury;  usually 
they  produce  stellate  tears.  Indirect  injuries  usually  are  effective  only 
when  the  liver  already  is  the  seat  of  disease,  though  id  falls  upon  the  feet 
or  buttocks  the  liver  may  be  ruptured  by  "counter-stroke,"  or  it  may 
burst  in  the  sagittal  plane  from  being  bent  upon  itself.  Hubbard 
(1906)  quotes  Henzelman's  statistics  (1886)  of  151  subcutaneous 
injuries  of  the  liver,  one-third  of  which  were  caused  by  indirect  violence. 
Though  direct  violence  usually  acts  from  the  front,  injury  may  be  due 

'  Four  other  patients,  not  included  in  the  above,  died  of  hemorrhage  before  operation 
could  be  done. 

-Two  other  patients,  not  included  in  the  above,  recovered  without  operation.  Pre- 
sumably they  had  a  subcapsular  or  central  rupture. 


596  INJURIES    OF    THE    LIVER    AND    BILIARY    PASSAGES 

to  falls  on  the  back,  as  in  Houghton's  patient  (1Q07) ;  to  lateral  pressure 
(Herzog,  1907),  or  even  to  muscular  action  (Waring).  In  Herzog's 
patient  the  accident  occurred  as  the  result  of  an  obstetrical  practice 
said  to  be  common  in  the  Philippine  Islands:  the  natives  place  a  folded 
cloth  around  the  loins  of  the  woman  in  labor,  and  one  or  two  persons 
make  traction  upon  it.  This  patient  died,  and  at  autopsy  a  rupture 
of  the  liver  was  found,  due  to  the  eleventh  rib  being  forced  into  the 
liver  substance. 

Ruptures  are  much  more  frequent  in  the  right  than  the  left  lobe 
of  the  liver,  and  upon  its  upper  surface  than  upon  its  lower.  In 
182  cases  analyzed  by  Thole  the  right  lobe  was  affected  six  times  as 
often  as  the  left. 

Ruptures  of  the  liver  are  divided  by  systematic  writers  into  three 
classes : 

1.  Rupture  of  the  hepatic  tissue  involving  the  capsule. 

2.  Separation  of  the  unruptured  capsule  from  the  liver  substance, 
with  subcapsular  hematoma. 

3.  Central  ruptures,  giving  rise  to  separate  or  confluent  hemato- 
mata,  which  may  develop  into  cysts  or  abscesses. 

The  first  class  is  the  most  important,  owing  to  the  necessary  occur- 
rence of  intraperitoneal  hemorrhage,  with  its  attendant  dangers. 
The  second  and  third  classes  may  prove  little  more  serious  than  a 
contusion,  unless  the  capsule  of  Glisson  eventually  ruptures,  or  unless 
secondary  infection  of  the  hematoma  occurs. 

Ruptures  involving  the  capsule  of  Glisson  may  be  single  or  multiple; 
superficial  or  deep;  linear,  stellate,  or  gaping;  the  liver  substance  may 
be  pulpefied;  portions  of  liver  may  be  detached  or  the  entire  organ 
may  be  torn  in  half  (Fig.  156). 

Symptoms. — Immediately  after  the  injury  there  usually  is  shock, 
with  nausea  and  vomiting,  followed  in  most  cases  by  symptoms  of 
internal  hemorrhage.  The  pulse  may  vary  considerably,  being  very 
slow  very  soon  after  the  injury  but  soon  increasing  in  frequency. 
Finsterer  (1912)  observed  marked  bradycardia  in  three  out  of  eight  cases 
of  injury  of  the  liver  by  contusion,  and  he  made  experimental  studies 
to  prove  the  value  of  this  symptom  in  diagnosing  rupture  of  the  liver. 
Bradycardia  occurs  in  some  cases  of  cholemia,  and  Finsterer  claims 
it  is  the  result  of  the  action  of  bile-acids,  and  states  that  even  if  on 
account  of  excessive  hemorrhage  the  pulse  does  not  become  slower 
yet  the  absorption  and  elimination  of  bile-salts  may  be  detected  by 
appropriate  tests  of  the  urine.  He  claims  that  the  pulse  is  the  most 
reliable  guide  in  those  cases  where  internal  hemorrhage  is  not  severe, 


RUPTURE    OF    THE    LIVER 


597 


and  where  rigidity  of  the  abdominal  muscles  possibly  may  be  thought 
to  be  due  to  a  parietal  injury  without  visceral  complication.  Particu- 
larly if  the  bradycardia  develops  while  the  patient  is  under  observation, 
or  if  it  is  present  at  first,  only  to  vanish  as  hemorrhage  progresses, 
should  injury  to  the  liver  be  suspected.  In  one  of  Finsterer's 
patients  the  pulse  was  forty-eight,  and  in  another  fifty- two  at  the 
time  of  the  first  examination.  Thus  a  slow  pulse  is  of  considerable 
diagnostic  importance,  though  a  rapid  pulse  does  not  b>  any  means 
exclude  visceral  injury.     He  has  collected,  in  all,   thirteen  cases  of 


Fig.   156. — Rupture  of  the  Liver;  from  a  Patient  in  the  Episcopal  HospitaL     (See  Case 

History,  page  599.) 


marked  bradycardia  due  to  this  cause.  Thole  found  bradycardia 
recorded  in  exceedingly  few  of  his  collected  cases,  and  thinks  no  sig- 
nificance should  be  attached  to  it. 

The  abdomen  at  first  is  soft  and  flat,  and  in  some  cases  may  remain 
so  for  hours;  usually,  however,  it  very  soon  becomes  rigid  and  board- 
like, and  later  distended.  Tenderness  is  more  or  less  general  soon 
after  the  injury  but  gradually  becomes  locahzed  over  the  hepatic 
region.  The  respirations  become  shallow  and  thoracic  in  an  endeavor 
to  keep  the  fiver  at  rest.  As  hemorrhage  increases  they  become 
sighing  in  character.  Generafiy  there  is  abdominal  pain,  and  very 
often  pain  in  the  back.  The  fiver  dullness  may  be  greatly  increased, 
and  in  some  cases  of  profuse  bleeding  shifting  dufiness  in  the  flanks 


598  INJURIES    OF    THE    LIVER    AND   BILIARY    PASSAGES 

may  be  detected.  Jaundice  may  occur  after  a  day  or  two,  especially 
if  operative  treatment  has  not  been  undertaken  promptly;  but  as 
a  rule  it  is  of  no  diagnostic  importance. 

The  diagnosis  of  rupture  of  the  liver  often  is  difScult,  especially 
soon  after  the  injury  has  been  received.  A  history  of  injury  in  the 
hepatic  region  always  should  make  one  suspect  rupture  of  the  liver. 
Hubbard  lays  stress  on  the  effect  of  heat  on  the  abdominal  muscles 
as  a  differential  diagnostic  sign.  In  simple  contusions  of  the  abdominal 
muscles  these  relax  after  the  appUcation  of  heat,  while  they  remain 
rigid  and  the  degree  and  extent  of  the  rigidity  increases  when  there 
is  an  intra-abdominal  traumatism.  LocaUzation  of  tenderness  and 
of  spasm  of  the  abdominal  muscles  often  points  to  the  organ  involved. 
Jaundice  coming  on  two  to  four  days  after  a  suspected  injury  of  the 
liver,  the  result  of  absorption  of  bile  through  the  peritoneum,  is  seen 
in  about  20  per  cent,  of  the  cases.  Jaundice  appearing  much  later 
generally  is  due  to  abscess  formation  in  the  hver. 

Prognosis. — The  prognosis  in  rupture  of  the  liver  is  greatly  modified 
by  the  treatment  instituted  and  the  length  of  time  elapsing  between 
the  injury  and  operation.  Edler  found  that  more  than  half  of  543 
collected  cases  of  rupture  of  the  Hver  died  from  hemorrhage  within 
twenty-four  hours  following  the  accident.  The  total  mortaHty  in 
this  series  of  collected  cases,  none  of  them  treated  by  operation,  was 
66.8  per  cent.  The  diagnosis,  in  the  case  of  patients  who  recover 
without  operation,  usually  is  rather  uncertain,  and  Mercade  (1902) 
probably  was  within  the  truth  when  he  claimed  a  death  rate  of  80  per 
cent,  without  operation.  It  cannot  be  denied  that  recovery  may 
occur  without  operation,  especially  in  the  cases  of  subcapsular  or 
central  rupture;  but  even  in  these  cases  a  deferred  operation  some- 
times has  had  to  be  undertaken  for  hepatic  or  subphrenic  abscess  or 
some  other  sequel  of  the  original  injury.  According  to  Finsterer 
such  cases  have  been  recorded  by  Graser,  Fertig  and  Chiari. 

Much  more  reliable  information  is  derived  from  statistics  which 
comprise  series  of  consecutive  cases  from  one  or  several  hospitals.  Such 
series  are  presented  in  the  following  table: 

Series  of  Consecutine  Operations  for  Ritptire  of  the  Liver 

Bartels  (1904) 6  operations  83  per  cent,  mortality- 

Boljarski  (191 1) 8  operations  100  per  cent,  mortality. 

Finsterer  (191 2)                       42  operations  69  per  cent,  mortality. 

Hagen  (1906) 12  operations  75  per  cent,  mortality. 

Wilms  (1905) 15'  operations  80  per  cent,  mortality. 

'Four  other  patients  died  before  operation  could  be  performed. 


RUPTURE    OF    THE    LIVER  599 

In  those  cases  not  subjected  to  immediate  operation  the  prog- 
nosis is  modified,  naturally,  by  the  extent  of  the  injury,  the  amount 
of  hemorrhage,  and  the  presence  or  absence  of  infection.  Usually 
there  is  extravasation  of  bile  into  the  peritoneal  cavity.  This  causes 
Httle  damage  if  it  is  sterile,  but  when  it  contains  bacteria,  or  when  it  is 
allowed  to  remain  indeiinitely  in  the  peritoneal  cavity  and  becomes 
infected  by  migration  of  bacteria  from  the  intestines,  spreading  peri- 
tonitis follows.  The  immediate  danger  following  the  injury  is  from 
hemorrhage;  the  remote  danger  is  from  sepsis. 

A  few  well-authenticated  cases  of  embolism  by  pieces  of  liver  tissue 
have  been  recorded.  Finsterer  mentions  the  fatal  cases  reported  by 
Marshall,  Hess,  Schmorl,  Zenker,  and  Williams.  Schnitzler  thought 
the  pulmonary  symptoms  in  his  patient,  who  recovered,  were  due  to  an 
embolus  of  hepatic  tissue. 

The  treatment  of  diagnosticated  or  strongly  suspected  rupture 
of  the  liver  consists  in  immediate  laparotomy  with  repair  of  the  lesion  in 
the  liver.  We  believe  with  Notzel  (1906,  1909)  that  shock  is  not  a 
contraindication  to  immediate  operation.  Hubbard  believes  that 
it  is  better  to  treat  the  shock  by  means  of  heat,  morphin,  strych- 
nin, and  saline  solution,  before  opening  the  abdomen.  As  the  great- 
est danger  comes  from  the  hemorrhage,  and  as  the  liver  tissue  tends 
to  prevent  collapse  of  the  bleeding  vessels,  we  feel  quite  certain  it 
is  safer  to  subject  the  patient  to  the  added  burden  of  an  operation 
than  tothe  added  burden  of  continuing  hemorrhage. 

In  some  cases,  however,  death  occurs  so  rapidly  that  there  is  no 
opportunity  for  operation.  This  was  true  in  the  patient  whose  liver 
is  represented  in  Fig.  156. 

Rupture  of  the  Liver;  Death 

A  man  aged  thirty-two  years  was  admitted  to  the  Episcopal  Hospital,  service 
of  Dr.  R.  H.  Harte,  Nov.  13,  1899.  He  had  been  caught  between  the  back  of  a 
wagon  and  the  pole  of  another  wagon,  the  pole  striking  the  patient  in  the  upper 
abdomen.  There  was  slight  discoloration  of  the  skin  posteriorly  at  the  level  of  the 
eighth  thoracic  vertebra.  The  patient  was  in  profound  shock  when  admitted, 
unconscious,  and  with  symptoms  of  internal  hemorrhage.  Death  occurred  ten 
minutes  after  admission. 

Autopsy. — Peritoneal  cavity  full  of  fluid  blood;  left  lobe  of  liver  nearly  detached 
from  right  by  rupture  running  parallel  to  the  great  transverse  fissure  and  about 
2  cm.  to  its  left.  Only  a  narrow  isthmus  of  liver  tissue  holds  the  left  lobe  to  the 
right,  this  isthmus  being  at  the  posterior  margin  (Fig.  156). 

The  abdominal  incision  should  be  made  near  the  median  Hne  in  the 
epigastric  region,  through  the  right  rectus  muscle.     The  convex  surface 


600  IN'JURIES    OF    THE    LIVER    AND    BILIARY    PASSAGES 

of  the  liver  may  be  reached  by  section  of  the  suspensory  ligament,  or  by 
resecting,  the  eighth,  ninth,  and  tenth  costal  cartilages  and  drawing  the 
ribs  outward,  as  described  at  page  295.  A  large  incision  may  be  re- 
quired, and  if  one  from  the  ensiform  to  the  umbilicus  near  the  median 
line  does  not  suffice,  the  best  exposure  will  be  secured  by  transverse 
division  of  the  rectus  at  the  level  of  the  umbilicus,  as  in  Czerny's  gall- 
bladder incision  (page  763). 

Hemorrhage  may  be  controlled  by  suture  or  by  packing  the  wound 
in  the  liver  with  gauze.  Temporary  clamping  of  the  pedicle  of  the 
liver  to  secure  hemostasis  was  proposed  by  Pringle,  according  to  Fin- 
sterer;  and  Baron  (1910)  devised  a  special  clamp  for  the  purpose.^  One 
blade  of  the  forceps  is  passed  through  the  foramen  of  Winslow  and  the 
other  in  front  of  the  gastro-hepatic  omentum.  Such  a  measure  is  seduc- 
tive in  theory,  but  we  should  be  fearful  of  injury  to  the  portal  vein.  The 
blood-pressure  in  the  liver  is  very  low,  and  if  the  surgeon  does  not  lose 
his  head  on  encountering  such  profuse  hemorrhage,  very  moderate 
pressure  with  gauze  on  the  bleeding  surface  is  sufficient  to  check  it. 

It  is  perfectly  feasible  to  suture  most  wounds  of  the  liver  with- 
out having  bleeding  along  the  suture  tract,  provided  the  u<ounds  are 
accessible.  In  the  case  of  lacerated  wounds,  where  the  hepatic  tissue 
is  pulpefied,  it  may  be  impossible  to  make  sutures  hold.  Various 
methods  of  liver  suture  are  described  in  Chapter  XXIV. 

Tamponade  of  the  wound  with  gauze  almost  always  is  much  easier 
than  suture,  but  it  is  a  method  that  entails  a  long  convalescence  and 
predisposes  to  infection.  Boljarski  found  that  for  patients  whose  liver 
wounds  had  been  tamponed  the  average  stay  in  the  hospital  was  sixty 
days.     This  was  the  case  in  the  patient  whose  history  is  appended. 

Rupture  of  Lfvtr;  Tamponade;  Recovery 

H.  G.,  male,  aged  twenty-eight  years,  admitted  to  the  German  Hospital  Novem- 
ber 9,  1909.  At  3  P.M.  on  the  day  of  admission  had  been  caught  between  two  heavy 
objects  crushing  the  lower  part  of  the  chest  antero-posteriorly.  On  admission, 
half  an  hour  after  injury  the  pulse  was  84,  temperature  98,  and  respirations  28. 
There  was  very  evident  fracture  of  the  tenth  and  eelventh  ribs  on  the  right  side. 
SmaU  area  of  dulness  in  both  flanks.  Liver  dulness  not  obliterated.  Very  slight 
rigidity  of  the  abdominal  muscles.  Peristalsis  present.  There  was  some  tenderness 
over  the  hepatic  region.  Hemoglobin  80  per  cent.  One  hour  later  there  were  signs 
of  internal  hemorrhage,  the  pulse  was  much  more  rapid,  the  skin  and  mucous 
membranes  were  becoming  blanched,  respirations  were  slightly  sighing  in  character, 
and  the  area  of  dullness  in  the  flanks  was  increasing.  Immediate  operation  was 
advised,  but  was  deferred  by  patient  until  7.30  p.m.,  four  hours  and  a  half  after  the 
injury. 

'  McDill's  experiments  are  referred  to  at  page  7g3, 


GUNSHOT    WOUNDS    OF    THE    LIVER  6oi 

Operation  by  Dr.  G.  G.  Ross,  Assistant  Surgeon  to  the  Hospital.  Ether  anes- 
thesia. Abdomen  opened  through  upper  right  rectus.  Peritoneal  cavity  filled  with 
blood.  Linear  tear  found  on  convex  surface  of  right  lobe  of  liver.  The  wound 
was  8  cm.  long,  very  deep,  and  gaping.  The  wound  in  the  liver  was  packed  in 
layers,  seven  pieces  of  gauze  being  used.  Blood  was  mopped  out  of  peritoneal 
cavity,  and  the  abdominal  wound  was  closed,  the  gauze  packing  emerging  at  upper 
end.  The  patient  was  greatly  shocked,  and  800  c.c.  of  saline  solution  were  given 
intravenously  during  operation ;  this  amount  was  repeated  three  hours  later. 

After  reacting,  the  patient  did  well.  The  last  piece  of  gauze  was  removed 
on  November  15,  sixth  day  after  operation.  The  sinus  healed  slowly,  but  was 
entirely  closed  when  the  patient  was  discharged  January  21,  1910. 

At  the  time  of  admission  the  patient's  hemoglobin  was  80  per  cent.  Two  days 
later  it  was  56  per  cent. 

When  a  tampon  is  used  it  was  formerly  taught  that  it  should  not 
be  removed  in  less  than  forty-eight  hours,  and  that  it  should  not  remain 
in  place  longer  than  three  or  four  days,  for  fear  of  inducing  the  formation 
of  a  persistent  biliary  fistula.  But,  as  Boljarski  (191 1)  pointed  out, 
secondary  hemorrhage  may  occur  up  to  the  sixth  or  seventh  day,  or 
even  later;  and  the  vast  experience  in  wounds  of  the  liver  acquired  by 
this  writer  in  Zeidler's  clinique  at  St.  Petersburg  should  have  great 
weight  in  bringing  surgeons  to  adopt  his  practice.  In  his  series  of 
cases  of  liver  injury  the  tampon  was  used  no  less  than  sixty  times,  and 
he  made  it  a  practice  not  to  loosen  the  pack  for  a  week,  and  even  then 
to  draw  it  out  only  by  degrees. 

The  actual  cautery,  and  the  use  of  live  steam  have  been  recom- 
mended for  the  control  of  hemorrhage  from  the  liver,  but  such  measures 
increase  the  dangers  of  secondary  hemorrhage. 

Omentoplasty  as  an  aid  in  controlling  hemorrhage  from  wounds 
of  the  liver  was  studied  experimentally  by  Loewy  (1901),  and  has  been 
used  by  Mauclaire  in  resection  of  the  liver  for  tumor,  and  in  a  case 
of  stab  wound,  with  success.  Boljarski  used  this  method  in  five 
cases  successfully:  the  omentum  is  stitched  to  the  borders  of  the 
hepatic  wound,  or  is  stuffed  into  the  wound,  if  large,  and  the  wound 
margins  are  then  sutured  together  over  it.  Boljarski  used  silk  and 
ordinary  intestinal  needles.  In  three  cases  the  abdominal  wound 
could  be  closed  without  drainage,  but  in  the  two  other  patients  drainage 
was  necessary.  The  average  stay  in  the  hospital  of  the  five  patients 
was  only  twenty-four  days,  which  compares  very  favorably  with  the 
average  stay  after  tamponade  of  sixty  days. 

Gunshot  Woixnds  of  the  Liver.— Owing  to  the  position  and  size 
of  the  liver,  gunshot  wounds  of  that  organ  occur  next  in  frequency 
to  those  of  the  intestine.     In  civil  practice  gunshot  injuries  of  the 


6o2  INJURIES    OF    THE    LrV'ER    AND    BILIARY    PASSAGES 

liver  represent  from  23  to  t,^  per  cent,  of  all  gunshot  wounds  involving 
the  abdomen;  but  in  only  about  12  per  cent,  of  such  wounds  is  the 
injury  of  the  liver  uncomplicated  by  lesions  of  other  viscera.  But 
of  163  cases  of  gunshot  wound  of  the  liver  occurring  during  the  German 
War,  reported  by  Wallace  (1917),  148  (91  per  cent.)  were  uncomplicated 
and  only  15  (9  per  cent.)  were  complicated  by  wounds  of  other  viscera. 
The  structures  most  often  wounded  in  complicated  cases  are  the  pleura, 
lung,  diaphragm,  stomach  and  colon. 

Gunshot  Wound  of  Pericardium,  Esophagus,  Diaphragm,  Liver,  and  Lung. 
Combined  Operation.    Death  from  Pneumonia. 

E.  F.,  female,  aged  seventeen  years,  was  admitted  to  Dr.  G.  G.  Davis's  service 
in  the  Episcopal  Hospital,  March  6,  1909.  The  bullet  had  entered  the  sixth  left 
intercostal  space  close  to  the  sternum,  and  lodged  beneath  the  skin  of  the  back  in 
the  eleventh  left  intercostal  space,  about  8  cm.  from  the  vertebral  line.  Shock 
was  present,  and  there  were  symptoms  of  internal  hemorrhage  and  of  wound  of  the 
lung.  No  evidence  of  injury  to  the  heart.  The  abdominal  muscles  were  so  rigid 
as  to  indicate,  in  connection  with  the  presumed  course  of  the  bullet,  that  there  was 
perforation  of  the  diaphragm  with  injury  of  the  abdominal  viscera. 

Operation  by  Dr.  Ashhurst,  2.15  a.m.,  five  hours  after  injury.  Ether  anesthesia. 
"Combined  operation."  (See  p.  285.)  Incision  from  tip  of  left  eighth  costal 
cartilage  downward  and  inward  to  mid-line,  obliquely  across  rectus  muscle.  Peri- 
toneum opened,  and  a  little  blood  found.  Better  exposure  was  secured  by  cutting 
across  the  eighth  costal  cartilage  and  splitting  the  diaphragm  upward  for  about  7  cm. 
In  doing  this  the  pleura  was  wounded  and  found  full  of  blood.  The  pleural  opening 
was  temporarily  closed  by  clamp.  Good  exposure  was  now  secured  of  the  under  sur- 
face of  the  diaphragm,  the  fundus  and  cardia  of  the  stomach,  the  left  lobe  of  the  liver, 
and  of  the  spleen.  There  was  no  active  hemorrhage,  and  no  wound  of  the  stomach, 
colon,  liver  or  spleen  was  found.  The  diaphragm  was  sutured,  and  the  abdominal 
incision  closed  around  a  gauze  wick.  The  original  skin  incision  was  theii  continued 
outward  in  the  seventh  intercostal  space  to  the  posterior  axillary  line,  and  the 
pleura  was  widely  opened.  There  was  very  great  dyspnea  until  the  pleura  was 
widely  opened,  whereupon  the  respirations  became  more  tranquil.  About  500  cc.  of 
fluid  blood  were  evacuated  from  the  pleural  cavity,  active  hemorrhage  continuing. 
On  the  pleural  surface  of  the  left  dome  of  the  diaphragm  was  a  hematoma,  about 
7.5  cm.  long  by  2.5  cm.  wide,  presumably  a  grooved  wound  made  by  the  buUet. 
The  lower  and  posterior  margin  of  the  lung  was  full  of  blood,  but  when  drawn  into 
the  wound  with  volsellum  forceps  no  active  hemorrhage  was  detected,  and  no 
sutures  were  inserted.  There  was  bleeding  from  the  wound  of  exit  in  the  posterior 
parietal  pleura.  This  was  tamponed,  and  the  thoracic  wound  was  closed  around 
the  gauze  wick.  The  buUet  was  then  removed  from  its  subcutaneous  position  by 
another  incision. 

Death  in  fifty-three  hours  from  double  septic  pneumonia. 

Autopsy. — The  bullet  entered  the  sixth  left  intercostal  space  and  penetrated 
the  pericardium  without  wounding  the  heart;  there  was  very  little  blood  in  the 
pericardium.     On   leaving   the   pericardium   the   bullet   entered    tlie   diaphragm, 


GUNSHOT    WOUNDS    OF    THE    LIVER  603 

grooving  the  esophagus  as  the  latter  passed  through  the  diaphragm.  The  bullet 
then  perforated  the  thin  margin  of  the  left  lobe  of  the  liver,  making  a  tunnel  2.5  cm. 
long.  It  then  re-entered  the  diaphragm,  penetrated  the  pleura,  passed  through  the 
lower  border  of  the  lung,  and  left  the  pleura  in  the  eleventh  intercostal  space. 
There  was  no  blood  in  the  peritoneal  cavity  and  no  peritonitis;  no  pus  and  little 
blood  in  the  pleural  cavity.     Death  from  diffuse  pneumonia  involving  both  lungs. 

The  immediate  effect  of  perforation  of  tlie  liver  by  a  bullet  is 
hemorrhage.  The  extent  of  the  hemorrhage  will  be  modified  by  the 
size  of  the  wound,  the  location  and  the  course  of  the  bullet,  and  some- 
what by  the  period  of  digestion,  since  the  hepatic  blood-vessels 
become  enormously  engorged  during  the  process  of  digestion.  Gunshot 
wounds  when  the  liver  is  in  this  condition  are  followed  by  more  profuse 
hemorrhage  than  after  digestion  has  been  completed. 

The  symptoms  of  uncomplicated  gunshot  wounds  of  the  liver 
are  chiefly  those  of  internal  hemorrhage.  Other  symptoms  are  com- 
paratively unimportant.  Shock  is  not  always  marked.  Pain  may  be 
severe  or  absent;  it  is  an  important  symptom  when  referred  to  the 
right  shoulder.  As  a  rule  muscular  rigidity  is  not  marked.  Janndice 
does  not  occur  for  some  days;  Edler  (1887)  says  it  develops  in  about 
20  per  cent,  of  the  cases. 

The  diagnosis  depends  on  the  position  of  the  wound  of  entrance 
of  the  bullet,  and  the  direction  in  which  it  travelled,  if  this  is  known 
or  if  it  can  be  ascertained  from  the  wound  of  exit  or  the  site  of  lodge- 
ment. Usually  symptoms  of  hemorrhage  are  sufficiently  marked 
to  warrant  a  diagnosis  of  wound  of  the  liver  when  the  course  of  the 
bullet  indicates  this  as  a  probability.  In  most  cases  the  complicating 
injuries  to  other  viscera  are  of  greater  importance  from  a  diagnostic 
and  surgical  standpoint  than  the  liver  injury. 

Prognosis. — Uncomplicated  gunshot  wounds  of  the  fiver  are  very 
rare  in  civil  life.  Finsterer  (191 2)  could  find  reports  only  of  twenty- 
six  operations  in  such  cases,  and  from  this  series  he  did  not  exclude 
wounds  of  the  pleura  or  slight  injuries  of  the  lung  which  often  are  negli- 
gible. Nineteen  of  these  twent3''-six  patients  recovered  including  one 
operated  upon  by  Finsterer  himself;  and  seven  died,  a  mortality  of 
27  per  cent.  Where  the  liver  wound  is  complicated  by  gunshot  wounds 
of  other  viscera,  the  death  rate  is  even  higher.  Among  eleven  consecu- 
tive cases  from  various  German  cliniques,  reported  by  Finsterer,  there 
were  three  deaths  (27.2  per  cent.);  of  Boljarski's  two  patients,  one 
died  (50  per  cent.). 

The  treatment  in  all  cases  of  gunshot  wound  of  the  liver  in  civil 
fife  is  immediate  operation.  Expectant  treatment  might  be  justified 
in  those  few  cases  where  the  bullet  is  of  small  calibre,  where  there  are 


6o4  INJURIES    OF    THE    LRER    AND   BILIARY    PASSAGES 

no  signs  or  symptoms  of  internal  hemorrhage  or  of  comphcating  injuries; 
or  where  no  facihties  exist  for  operation.  But  in  all  other  cases  opera- 
tion should  be  undertaken  before  time  has  elapsed  for  signs  of  peritonitis 
to  arise.  Wallace  (19 17)  believed,  from  his  study  of  war  wounds  (to 
which  reference  was  made  at  p.  602),  that  if  one  could  be  sure  the 
injury  to  the  liver  was  uncompHcated,  no  operation  need  be  done;  but 
as  this  never  was  certain,  exploration  was  demanded  in  all  cases. 
Often  the  signs  of  internal  hemorrhage  are  so  urgent  that  immediate 
operation  is  required  on  this  account.  The  wound  of  entrance 
should  be  disinfected,  as  advised  at  page  294,  and  the  Uver  exposed  as 
recommended  in  cases  of  rupture  of  this  organ  (page  599).  The  bleed- 
ing from  the  wound  in  the  Uver  should  be  controlled  by  suture,  packing, 
or  omentoplasty. 

Stab-wounds  of  the  Liver. — The  relative  frequency  of  these 
injuries  has  been  indicated  at  page  595.  Among  Boljarski's  tifty-five 
cases  there  were  thirty-two  uncomplicated  by  injuries  to  other  viscera. 
Stab-wounds  are  followed  by  profuse  hemorrhage,  the  bleeding 
being  much  more  marked  than  in  gunshot  wounds.  The  symptoms 
are  those  of  hemorrhage,  possibly  with  symptoms  of  complicating 
injury  to  other  viscera,  as  in  the  case  of  rupture  and  gunshot 
wounds. 

The  diagnosis  of  stab  wounds  of  the  liver  is  based  on  the  history, 
together  with  the  location  of  the  external  wound  in  the  region  of  the 
liver,  and  on  the  presence  of  hemorrhage.  It  is  impossible  to  deter- 
mine positively  from  the  symptoms  alone  whether 'or  not  the  liver 
has  been  injured.  Under  ordinary  circumstances  the  surgeon  must 
content  himself  with  the  diagnosis  of  internal  hemorrhage. 

The  prognosis  after  prompt  operation  is  comparatively  favor- 
able. A  few  patients  may  die  before  opportunity  for  operation  is 
afforded.  Operative  treatment  was  adopted  in  all  of  Boljarski's 
hfty-iive  patients:  seventeen  deaths  occurred,  a  mortahty  of  40  per 
cent.  Among  the  thirty-two  uncomplicated  cases,  however,  there 
were  only  four  deaths  (12,5  per  cent.);  while  of  the  twenty-three  cases 
complicated  by  other  abdominal  or  serious  thoracic  injuries,  no  less 
than  thirteen  terminated  fatally  (56  per  cent.). 

The  treatment  consists  in  immediate  operation.  If  the  fact  of 
penetration  of  the  abdominal  cavity  is  uncertain,  the  surgeon  should 
explore  the  wound  with  the  precautions  advised  at  page  289,  for  the 
reasons  there  stated.  In  cases  where  the  fact  of  penetration  is  as- 
sured by  the  prolapse  of  abdominal  contents  (a  condition  met  with 
in  fifteen  out  of  Boljarski's  fifty-five   cases),   the  peritoncaLcavity 


STAB-WOUNDS    OF    THE    LIVER  605 

may  be  opened  at  once.  If  the  stab  wound  in  the  abdominal  parietes 
is  in  a  convenient  location,  the  operative  incision  may  be  made  through 
it.  It  is  better  when  possible  to  operate  through  the  stab  wound 
than  to  make  a  new  incision,  although  the  latter  of  course  is  to  be 
preferred  if  it  facihtates  rapid  work  and  allows  more  convenient 
treatment  of  the  rent  in  the  liver.  The  latter  should  be  closed  by 
suture,  packing  or  omentoplasty,  as  described  at  page  60 1. 

Three  Stab  Wounds  (Suicidal)  of  the  Liver.     Suture.    Recovery. 

G.  S.,  male,  Russian,  aged  thirty  years,  a  tailor  by  occupation,  attempted  to  kill 
himself  at  1.30  p.m.,  January  5,  1912,  by  stabbing  himself  with  his  long  tailor's 
shears.  He  was  brought  to  the  Episcopal  Hospital,  and  admitted  to  Dr.  Frazier's 
service.  Examination  at  5  p.m.  showed  that  there  was  no  shock.  The  pulse  was 
120  to  130,  considerably  faster  than  on  admission,  when  it  was  about  100.  He  was 
rather  pale,  and  quite  impassive.  There  was  no  tenderness  or  rigidity  of  the 
abdomen.  There  were  five  stab  wounds  in  the  epigastric  region.  The  largest, 
about  4  cm.  long,  was  just  to  the  right  of  the  mid-line,  and  close  to  the  costal  margin, 
dividing  the  fibres  of  the  right  rectus  muscle  transversely.  No  prolapse  of  abdom- 
inal contents.     No  free  fluid  in  the  flanks. 

Operation  by  Dr.  Ashhurst,  at  5.30  p.m.,  four  hours  after  injury.  Ether  anes- 
thesia, preceded  by  nitrous  oxide.  Gloved  finger  inserted  into  largest  stab  wound 
entered  peritoneal  cavity  and  recognized  the  liver  immediately  beneath  the  wound. 
Incision  through  right  rectus  muscle,  close  to  median  line,  passing  through  the 
largest  of  the  stab  wounds.  Free  blood  was  present  in  the  peritoneal  cavity.  The 
stomach  and  omentum  were  packed  oflf  with  gauze,  and  the  incision  extended  up 
beside  the  ensiform  cartilage.  On  the  upper  convex  surface  of  the  right  lobe  of  the 
liver,  about  8  cm.  from  its  anterior  border,  there  was  a  stab  wound,  bleeding  ac- 
tively. By  elevating  the  patient's  lumbar  spine,  this  wound  became  accessible, 
and  was  closed  with  one  mattress  suture  of  chromic  catgut,  in  a  curved  intestinal 
needle.  Many  clots  and  some  fluid  blood  sponged  away  from  right  subphrenic 
space.  Through  a  stab  wound  in  the  suspensory  ligament  of  the  liver  a  flood  of 
blood  came  from  the  left  lobe.  The  suspensory  ligament  therefore  was  divided 
as  far  back  as  the  lateral  ligaments  of  the  liver,  and  large  quantities  of  fluid  and 
clotted  blood  were  evacuated  and  wiped  away  from  above  the  left  lobe.  By 
depressing  the  liver  two  more  stab  wounds  were  found,  both  on  the  upper  surface 
of  the  left  lobe,  neither  penetrating  to  its  undersurface.  Only  one  was  bleeding 
actively.  This  was  closed  with  one  mattress  suture  of  chromic  catgut  (Fig.  157). 
The  left  subphrenic  space  was  wiped  dry.  The  stomach,  gaU-bladder,  pylorus, 
omentum,  and  transverse  colon  were  examined,  but  no  further  lesions  were  found. 
The  suspensory  ligament  of  the  liver  was  then  repaired  by  sutures,  thus  reattaching 
the  liver  to  the  diaphragm.  The  abdominal  wound  was  closed  without  drainage. 
The  smaller  stab  wounds  of  the  abdominal  wall  were  tamponed.  The  operation 
lasted  fifty  minutes,  and  during  its  performance  1000  c.c.  of  saline  solution  were 
administered  intravenously. 

Culture  from  the  blood  evacuated  during  operation  (about  500  c.c.)  remained 
sterile. 


6o6 


INJURIES    OF    THE    LIVER    AND    BILIARY    PASSAGES 


Recovery-  was  slow  owing  to  pulmonar)-  complications.  For  signs  of  effusion 
in  the  pleural  cavities  (Dr.  Geo.  W.  Norris)  aspiration  was  done  on  both  sides  on 
January  22,  and  on  the  right  side  on  January'  28  and  February'  7.  But  at  no  time 
was  fluid  found. 

The  patient  developed  melancholia.     He  could  not  be  made   to  eat.     His 


Fig.  157. —  Stab-wounds   of  the  Liver,  Exposed  by    Division  of    the  Suspensory    Liga- 
ment.    From  a  Patient  in  the  Episcopal  HospitaL     (See  Case  History,  p.  605.) 


abdominal  wounds  were  slow  in  healing.  He  was  finally  discharged,  sound  phys- 
ically and  mentally,  on  May  11,  1912,  more  than  four  months  after  his  attempt  at 
suicide.  For  the  last  month  of  his  stay  in  the  hospital  he  had  done  much  work  in 
the  ward,  helping  the  orderlies,  etc. 


traumatic  rupture  of  the  gall-bladder  607 

Injuries  of  the  Gall-bladder  and  Biliary  Passages 

Injuries  to  the  gall-bladder  and  ducts  occur  less  frequently  than 
injuries  to  the  liver. 

Subcutaneous  ruptures  are  the  commonest.  They  are  very  seldom 
coincident  with  injuries  to  the  liver;  among  the  260  cases  of  rupture 
of  the  liver  collected  by  Thole  (1909),  there  were  only  two  instances 
where  the  gall-bladder  also  was  ruptured.  Thole  adds  thirteen  cases 
of  rupture  of  the  gall-bladder  or  bile-ducts  to  the  sixty-three  cases 
collected  in  1903  by  Lewerenz.  Previous  disease  of  the  biUary  tract 
predisposes  it  to  rupture.  A  distended  gall-bladder  such  as  is  often 
seen  in  the  presence  of  an  obstructed  cystic  duct  may  readily  be 
ruptured  by  a  slight  fall  on  the  side,  or  by  a  contusion. 

The  fundus  of  the  gall-bladder,  which  is  the  most  exposed  portion 
of  the  bile-passages,  is  most  frequently  injured.  Among  the  sixty- 
three  cases  of  rupture  of  the  biliary  passages  collected  by  Lewerenz,  the 
site  of  the  lesion  was 

In  the  gall-bladder 24  cases 

In  the  choledochus 10  cases 

In  intra-hepatic  bile  ducts  8  cases 

In  the  hepatic  duct 6  cases 

In  the  cystic-duct i  case 

Not  mentioned 14  cases 

The  injuring  force  may  also  cause  complicating  injuries  of  the 
adjacent  structures,  such  as  the  liver,  stomach,  intestine,  etc.  Kil- 
gour  (1841)  reported  a  case  in  which  a  portion  of  the  liver  with  its 
attached  gall-bladder  was  completely  separated  from  the  rest  of 
the  liver.  Paget  (1912)  reported  a  case  in  which  the  patient  was 
run  over  by  a  sulky.  The  Uver  had  been  torn  from  its  suspensory 
ligament  and  rotated  forward.  The  anterior  edge  of  the  liver  was 
flattened  out  and  adherent  to  the  transverse  colon.  The  gall-bladder 
had  been  torn  from  its  bed  in  the  liver  and  was  suspended  by  a  pedicle 
formed  by  the  cystic  duct  and  vessels.  Bile  was  being  discharged 
from  a  tear  in  the  common  duct.  The  patient  recovered  after  two 
operations,  death  being  prevented,  according  to  Paget,  by  hypodermic 
injections  of  pituitary  gland. 

The  early  symptoms  presented  by  rupture  of  the  biliary  passages 
are  similar  to  those  of  other  internal  injuries:  pain,  shock,  vomiting 
and  restlessness.  Signs  of  hemorrhage  are  not  so  marked  as  after 
rupture  of  the- liver,  as  bleeding  never  is  so  profuse.  Peristalsis  may  be 
present  or  absent.     Dullness  may  be  detected  in  the  right  flank  and 


6o8  INJURIES    OF    THE    LIVER    AND    BILIARY    PASSAGES 

later  in  the  left  flank.  Vomiting  in  some  cases  has  been  continuous. 
The  abdomen  becomes  distended  and  if  the  bile  is  so  infectious  as  to 
cause  peritonitis,  the  abdomen  becomes  tympanitic.  Sterile  bile, 
while  it  may  give  rise  to  very  decided  symptoms,  does  not  cause  fatal 
peritonitis.  If  the  bile  i?  allowed  to  remain  in  the  peritoneal  cavity  *'or 
a  considerable  length  of  time,  the  intestine  becomes  covered  with  a 
fibrinous  membrane  which  may  be  peeled  off  (Kehr).  Kehr  (1904) 
states  that  as  much  as  twenty  litres  of  bile  have  been  known  to  collect 
in  the  abdominal  cavity.  As  the  bile  is  being  absorbed  by  the  peri- 
toneum, generally  after  the  third  or  fourth  day,  symptoms  of  cholemia 
develop. 

The  picture  presented  at  a  later  period  will  be  modified  by  the  pres- 
ence or  absence  of  infection.  The  bile  is  a  good  culture  medium  and 
the  presence  of  micro-organisms  will  give  rise  to  a  wide-spread  peri- 
tonitis. Bacteria  may  enter  the  peritoneal  cavity  from  the  duodenum 
through  the  rent  in  the  bile-passages;  or  if  there  was  cholangeitis 
immediately  prior  to  the  injury  almost  invariably  peritonitis  will 
ensue. 

The  diag)wsis  is  based  on  the  history  of  injury  to  the  abdomen 
or  lower  thorax,  with  a  train  of  symptoms  which  points  to  visceral 
injuries.  The  most  characteristic  sign  of  injury  to  the  bile-passages  is 
the  jaundice  which  usually  appears  in  three  or  four  days,  due  to  the 
reabsorption  of  the  extravasated  bile.  This  jaundice  is  not  noted  so 
frequently  in  rupture  of  the  liver.  In  a  few  instances  the  only  thing 
suggesting  injury  to  the  biliary  tract  is  the  history  of  a  blow  or  injury 
in  the  right  hypochondrium;  the  other  signs  and  symptoms  are  those 
following  any  internal  injury-  with  the  exception  of  signs  of  excessive 
hemorrhage.  The  following  case  illustrates  some  of  the  conditions 
found  at  time  of  operation: 

Rupture  of  the  Gall-bl.adder.     Cholecystostomy.    Recovery 

J.  T.,  male,  aged  thirteen,  admitted  to  the  Children's  Hospital  of  the  Mary  J. 
Drexel  Home,  December  29,  1906.  Three  days  before  admission  he  had  been 
kicked  in  the  upper  abdomen  while  playing  basket  ball.  He  was  unconscious  for  a 
few  moments,  and  began  vomiting  one  hour  after  receiving  the  injur>'  and  continued 
vomiting  everything  ingested  for  the  next  forty-eight  hours.  On  admission  patient 
had  a  temperature  of  100°  F.,  and  a  rapid  pulse  of  good  volume.  \"omitus  was 
greenish  in  color,  with  no  odor.  Urine  was  normal.  There  was  no  discoloration 
of  the  skin  at  the  site  of  injurj'.  Jaundice  was  not  present.  The  abdomen  was 
very  much  distended,  the  onset  of  this  symptom  having  been  noted  thirty-si.\ 
hours  after  the  injury.  There  was  no  rigidity  of  the  abdominal  muscles.  The  boy 
complained  of  pain  in  the  right  hypochondrium,  but  there  was  no  mass  palpable  and 
no  area  of  tenderness  could  be  detected.     Both  flanks  were  dull  on  percussion. 


TRAUMATIC   RUPTURE    OF    THE    GALL-BLADDER  609 

Operation  by  Dr.  Deaver,  December  29,  1906.  On  opening  the  peritoneum, 
there  was  a  gush  of  a  large  quantity  of  greenish-yellow  fluid,  resembling  bile.  The 
entire  abdomen  and  pelvis  were  filled  with  bile  which  was  being  discharged  from  a 
rupture  in  the  fundus  of  the  gall-bladder.  The  abdomen  was  flushed  out  with  saline 
solution.  There  was  no  evidence  of  peritonitis.  Cholecystostomy  was  performed 
and  the  pelvis  was  drained  through  a  separate  incision.  No  injury  to  any  other 
viscus  could  be  found.     The  patient  recovered. 

The  prognosis  in  rupture  of  the  gall-bladder  and  ducts  should 
be  favorable  in  all  cases  where  early  operation  is  performed.  Of 
twenty-nine  cases  in  which  no  operation  was  done,  collected  by  Edler, 
twenty-two  died.  Septic  peritonitis  will  follow  in  all  cases  where  the 
bile  in  the  peritoneal  cavity  becomes  infected,  and  the  prognosis  under 
such  conditions  is  much  more  grave.  Even  where  the  bile  as  originally 
efTused  is  aseptic,  it  serves  as  such  a  good  culture  medium  that  its 
secondary  infection  from  the  intestinal  tract  or  through  the  blood 
stream  is  very  probable.  In  Courvoisier's  series  of  thirty-four  cases 
of  subcutaneous  rupture  of  the  biliary  passages,  death  occurred  in 
twenty-two,  in  five  from  collapse  within  the  first  thirty  hours  and  in 
seventeen  from  peritonitis  and  the  toxic  action  of  the  absorbed  bile. 
He  also  reported,  in  his  fourteen  cases  of  injury  due  to  penetrating 
wounds,  three  deaths  from  collapse  and  six  from  sepsis.  Uncomplicated 
injury  of  the  biliary  passages  allows  a  much  more  favorable  prognosis 
than  the  complicated  cases.  In  the  latter  instances  the  injuries  to  other 
viscera  are  of  far  more  moment  than  the  injury  to  the  gall-bladder  or 
ducts. 

The  treatment  consists  in  immediate  laparotomy  with  repair  or 
drainage  of  Ihe  injured  part.  If  the  diagnosis  is  uncertain  we  believe 
it  is  much  safer  to  explore  the  abdomen  than  to  wait  until  a  positive 
diagnosis  of  internal  injury  is  made  from  the  presence  of  jaundice,  a 
marked  distention  of  the  abdomen,  the  presence  of  spreading  peritonitis, 
etc.  Incision  of  the  abdominal  walls  with  inspection  of  the  viscera  we 
believe  to  be  better  surgery  than  removal  of  the  fluid  contents  of  the 
peritoneal  cavity  by  means  of  the  aspirating  trocar  and  canula.  Cour- 
voisier  reckoned  that  repeated  aspiration  might  cure  33.3  per  cent, 
of  patients,  while  66.6  per  cent,  would  perish  from  peritonitis  or  ca- 
chexia. Terrier  and  Auvray  (1896)  collected  seventeen  cases  of  rupture 
of  the  biliary  passages  in  which  aspiration,  at  times  repeated,  had 
been  performed,  ten  of  the  patients  recovering.  Unless  the  rent 
in  the  bile-passages  is  very  small  so  that  it  may  be  closed  by  plastic 
exudate  in  a  short  time,  aspiration  will  not  remedy  matters  as  more 

bile  will  be  constantly  poured  into  the  abdomen  and  absorbed.     Aspira- 
39 


6lO  INJURIES    OF    THE    LRER    AND   BILIARY    PASSAGES 

tion  can  only  remove  the  bile  from  the  peritoneal  cavity;  it  does  not 
effect  a  closure  of  the  rent  in  the  injured  structures. 

When  the  opening  in  the  gall-bladder  is  small,  it  maj'  be  closed 
and  the  external  wound  closed  without  drainage  after  evacuation  of 
most  of  the  fluid  found  in  the  abdomen.  Flushing  or  irrigation  of 
the  peritoneal  cavity  is  to  be  condemned.  When  the  rupture  is  of 
considerable  extent,  the  gall-bladder  should  be  drained;  or  if  the  gall- 
bladder has  been  badly  torn  or  shows  the  presence  of  marked  disease, 
it  should  be  removed.  When  the  common  duct  is  ruptured  the  opening, 
if  small,  may  be  closed ;  if  the  rent  is  large,  drainage  by  means  of  a  rubber 
tube  should  be  instituted.  If  the  entire  lumen  has  been  severed,  the 
posterior  wall  of  the  duct  may  be  sutured,  with  drainage  bj'  means  of  a 
T-shaped  tube  from  the  remaining  opening  in  the  anterior  portion;  or 
some  form  of  anastomosis  between  the  bile-tract  and  intestine  may  be 
done.  In  all  cases,  however,  in  which  there  is  evidence  of  cholecystitis 
or  cholangeitis,  drainage  should  be  instituted,  and  all  attempts  at 
radical  operation  postponed  until  the  patient  becomes  convalescent. 

Retroperitoneal  Ruptures  of  the  Bile-ducts. — This  subject  was 
referred  to  at  p.  453  in  connection  with  biliarj'  peritonitis. 

Penetrating  wounds  of  the  gall-bladder  are  quite  rare.  Thole 
gives  references  to  seventeen  cases  in  which  operation  was  done: 
thirteen  patients  recovered,  and  four  died,  a  mortality  of  23.5  per  cent. 
He  found  no  published  cases  of  open  wounds  of  the  bile-ducts. 


CHAPTER  XXI 
SURGERY  OF  THE  PANCREAS 

Historical. — The  term  pancreas,  from  the  Greek  xai*  Kpeas,  meaning 
hterally  "all  flesh,"  is  found  in  the  writings  of  Galen;  and  it  was 
thought  by  Haller  that  there  was  a  reference  to  it  in  the  apocryphal 
work  of  Hippocrates  (vrept  adevoiv).  According  to  Galen,  an  anatomical 
controversy  arose  over  the  pancreas  between  Herophilus  and  Eudemus 
(fourth  century  B.  C),  the  latter  of  whom  stated  that  a  fluid  emptied 
out  of  the  pancreas  into  the  bowels  and  aided  in  digestion;  yet  this 
interesting  fact  was  entirely  forgotten  under  the  influence  of  the  humoral 
pathology  of  Galen  (second  century  A.  D.),  who  followed  the  teaching 
of  Aristotle  that  the  pancreas  acted  as  a  cushion  or  buffer  for  the  stomach 
and  the  neighboring  vessels.  Even  the  early  anatomists,  such  as 
VesaUus,  Fallopius,  and  Bauhinus  knew  nothing  of  the  function  of 
the  parjcreas,  though  it  is  said  that  Alberti  (1578)  and  Heurnius  (1599) 
made  it  the  subject  of  dissertations.  Wirsung  (1642)  described  the 
duct  which  bears  his  name,  but  his  contemporary,  Asellius,  confused 
the  pancreas  with  the  retroperitoneal  or  mesenteric  lymphatics;  while 
some  held  that  it  acted  as  a  filter  for  the  secretions  of  the  liver  and 
the  spleen. 

In  1663  Regner  de  Graaf  published  a  work  on  the  nature  and 
use  of  pancreatic  juice;  he  was  also  the  first  to  describe  pancreatic 
calculi.  This  was  long  before  Santorini"s  work,  which,  however, 
was  not  published  until  1775,  thirty-eight  years  after  the  author's 
death.  During  this  period  (seventeenth  and  eighteenth  centuries) 
the  pancreas  was  associated  in  the  medical  mind  with  such  diseases  as 
melancholy,  hysteria,  and  epilepsy.  Such  ideas  were  soon  abolished, 
however,  by  the  physiological  and  pathological  discoveries  of  the  nine- 
teenth century.  Claude  Bernard  described  the  pancreatic  ferment  in 
1856,  and  the  pathological  anatomists  of  the  day,  Cruveilhier,  Rokitan- 
sky,  Virchow,  v.  Recklinghausen,  and  later,  Orth,  Langerhans,  and 
Dieckhoff,  laid  the  foundation  of  our  present  knowledge  of  pancreatic 
diseases  by  studying  the  gland  post-mortem. 

Hemorrhage  in  connection  with  diseases  of  the  pancreas,  the  so- 
called  "pancreatic  apople.xy,"  was  first  noted  in  1866  by  Spiess. 

611 


6l2  SURGERY  OF  THE  PANCREAS 

Fat  necorsis  accompanying  acute  pancreatitis  was  first  described 
by  Balser,  who  noticed  it  first  at  autopsy  in  1879;  but  the  publi- 
cations of  Fitz,  beginning  in  1889,  were  the  first  to  make  the  pro- 
fession realize  the  importance  of  the  acute  affections  of  the  pancreas. 

Though  the  connection  between  pancreatic  diseases  and  diabetes 
was  suggested  by  many  writers'  (Chopart,  1791;  v.  Recklinghausen, 
1864;  Lancereaux  1877),  it  was  not  firmly  established  until  the  publi- 
cation in   1889  of  V.  Mering's  and  IMinkowski's  experimental  work. 

Gussenbauer,  in  1882,  was  the  first  to  operate  successfully  by  lapar- 
otomy in  a  case  of  pancreatic  cyst,^  though  Lii eke  (1867)  and  Rokitansky 
(1881)  had  pre\'iously  done  such  operations  unsucessfully,  and  Thiersch 
(1881)  and  Kulenkampff  (1881)  had  opened  pancreatic  cysts  with 
success,  in  two  stages.  But  the  true  Father  of  Pancreatic  Surgery  is 
Nicholas  Senn,  who  in  1886  published  his  experimental  and  clinical 
researches,  with  the  object,  as  he  modestly  stated,  of  laying  a  founda- 
tion for  the  rational  treatment  by  surgical  means  of  some  of  the  diseases 
of  the  pancreas.  In  1896  Riedel  first  recognized  chronic  interstitial 
pancreatitis  at  operation;  but  it  is  chiefly  to  the  teaching  and  example 
of  Mayo  Robson,  from  the  year  1900  on,  that  modern  pancreatic 
surgery  owes  its  inspiration  and  guidance. 

Congenital  Anomalies,  Displacements,  etc. — The  pancreas  very 
occasionally  may  be  entirely  absent;  three  such  cases,  associated 
with  other  congenital  anomalies  incompatible  with  life,  are  mentioned 
by  Lancereaux  (1899).  On  the  other  hand,  in  a  certain  proportion  of 
bodies  there  are  so-called  accessory  pancreases.  Letulle  (1900)  found 
this  condition  six  times  among  two  hundred  bodies  examined  postmor- 
tem, while  Opie  (1903)  found  it  only  ten  times  in  eighteen  hundred 
autopsies.  It  is  probable  that  systematic  search  might  reveal  one  or 
more  accessory  pancreases  in  a  fairly  large  proportion  of  autopsies. 
These  accessory  glands  are  usually  of  small  size,  comparable  to  a  pea  or 
bean,  or  even  smaller,  being  verj-  seldom  so  large  as  a  nut;  they  are 
situated  in  the  walls  of  the  various  portions  of  the  alimentary  tract, 
usually  in  the  muscular  coat;  and  they  nearly  always  have  clearly 
recognizable  ducts.  In  a  few  instances  islands  of  Langerhans  have  been 
present.  In  the  cases  collected  by  Robson  and  Cammidge  (1907),  the 
accessory  pancreas  was  situated  in  the  stomach  in  eleven  instances, 
in  the  duodenum  in  sLx,  in  the  jejunum  in  eleven  (nearly  all  close  to  its 

'  Cawley  (i  788)  is  quoted  (by  the  name  Cowley)  by  many  recent  writers  on  the  pancreas 
as  one  of  the  earliest  to  recognize  this  condition.  Though  the  pancreas  of  his  patient 
was  full  of  stones,  he  distinctly  states  liis  belief  that  the  seat  of  diabetes  is  in  the  kidneys, 
and  the  lesions  of  the  liver  and  pancreas  are  the  result,  not  the  cause  of  that  disease. 

-  Pancreatic  cyst  was  first  studied  by  Engel  in  1S41. 


CONGENITAL   ANOMALIES  613 

duodenal  end),  in  the  ileum  in  five  (and  always  in  association  with  an 
intestinal  diverticulum,  not  Meckel's),  and  in  a  congenital  umbilical 
fistula  in  one  case.  The  accessory  pancreas  may  occur  as  a  single, 
isolated,  glandular  mass,  or  several  masses  may  be  distributed  along 
the  gastro-intestinal  tract.  Several  cases  are  on  record  of  an  accessory 
pancreas  at  the  duodenal  opening  of  the  duct  of  Wirsung;  and  in 
almost  all  individuals,  lobules  of  pancreatic  tissue  surround  the  duct 
of  Santorini  as  it  passes  through  the  duodenal  wall  (Opie).  Usually 
all  accessory  glands  are  found  at  autopsy  to  be  more  or  less  diseased,  and 
as  the  total  amount  of  glandular  tissue  is  very  small  it  has  been  quest- 
tioned  whether  it  can  in  any  efiicient  way  supplement  the  functions 
of  the  pancreas  itself. 

That  portion  of  the  head  of  the  pancreas  which  lies  furthest  to 
the  patient's  left  sometimes  becomes  more  or  less  separated  from 
the  rest  of  the  gland  by  the  superior  mesenteric  vessels,  which  emerge 
just  above  it  from  between  the  body  of  the  pancreas  and  the  transverse 
duodenum.  This  partially  isolated  portion  of  the  head  is  sometimes 
described  as  the  Pancreas  Minus,  but  is  not  truly  an  accessory  gland. 
Other  portions  of  the  pancreas  occasionally  are  more  or  less  isolated 
from  the  remainder  of  the  gland,  this  condition  being  described  by 
Glinski  (1901),  who  studied  the  subject  carefully,  as  Pancreas  Divisum. 
That  portion  of  the  pancreas  associated  with  the  duct  of  Santorini, 
which  arises  as  a  separate  outgrowth  from  the  posterior  wall  of  the 
duodenum,  is  that  which  is  most  often  separated  from  the  rest  of 
the  gland,  which  is  developed  as  a  twin  outgrowth  from  the  duodenal 
wall.  Normally  it  coalesces  with  the  portion  developing  around  the 
duct  of  Wirsung,  and  in  the  adult  the  body  and  tail  of  the  pancreas 
are  more  apt  to  drain  through  the  duct  of  Wirsung  than  through 
the  duct  of  Santorini  around  which  they  were  primarily  developed. 

The  head  of  the  pancreas  may  surround  the  duodenum  com- 
pletely, constituting  the  so-called  Ring-formed  Pancreas  {Pancreas 
Annulare);  Robson  and  Cammidge  refer  to  nine  such  cases.  In  a  few 
instances  this  rare  condition  has  simulated,  soon  after  birth,  infantile 
stenosis  of  the  pylorus;  Vidal  (1905)  successfully  resorted  to  gastro- 
enterostomy in  such  a  patient  three  days  after  birth.  Symptoms 
may  not  develop  until  adult  life,  when  chronic  pancreatitis,  car- 
cinoma, etc.,  affecting  such  an  abnormally  situated  pancreas,  may 
produce  occlusion  of  the  duodenum,  which  can  be  distinguished  from 
pyloric  stenosis  only  with  the  greatest  difficulty.  Lerat  (1910)  treated 
such  a  case,  in  a  woman  aged  forty  years,  by  partial  pancreatectomy. 


6l4  SURGERY  OF  THE  PANCREAS 

Displacement  of  the  pancreas  is  very  unusual,  owing  to  its  tixed 
retroperitoneal  position.  Sappey,  according  to  Korte  (1898),  claimed 
that  tight  lacing  might  eventually  lead  to  displacement  of  the  pan- 
creas, by  compressing  the  lower  thorax.  The  tail  is  the  least  well 
fixed  portion,  and  occasionally  is  dragged  from  its  moorings  by  a 
wandering  spleen  (Helm  and  Klob,  1856;  Estes,  1882;  Runge,  1895). 
Solid  tumors  of  the  pancreas  may  also  cause  its  displacement;  in  one- 
fourth  of  the  seventeen  cases  studied  by  Finney  (1910),  the  tumor 
was  freely  movable. 

Among  the  276  cases  of  diaphragmatic  hernia  collected  by  Lacher 
(1880),  the  pancreas  was  among  the  organs  displaced  into  the  thorax 
in  no  less  than  twenty-seven  instances;  while  this  was  the  case  in 
two  out  of  the  twenty-six  cases  of  congenital  diaphragmatic  hernia 
collected  by  0.  Mayor  in  1891,  which  had  been  reported  since  the 
appearance  of  Lacher 's  paper.  Such  cases  have  very  little  surgical 
interest,  so  far  as  the  pancreas  is  concerned,  as  any  symptoms  which 
may  arise  from  interference  with  its  function  are  sure  to  be  over- 
shadowed by  the  changes  induced  in  the  stomach  and  intestines. 

The  pancreas  has  been  found  three  times  in  a  congenital  umbil- 
ical hernia,  according  to  Korte  (1898);  who  also  states  that  E.  Rose 
and  Rahn  have  each  found  it  in  a  similar  hernia  in  adults.  Finally, 
reference  must  be  made  to  the  remarkable  case  observed  in  1805  by 
Baud  in  which  the  pancreas  formed  part  of  a  complicated  case  of 
intussusception.     Guibert  in  1829  described  a  somewhat  similar  case. 

Infections  of  the  Pancreas 

Pathogenesis. — Infection  of  the  pancreas  may  occur  in  any  one  of 
four  ways:  (i)  through  the  blood  stream;  (2)  along  the  excretory 
ducts  of  the  pancreas;  (3)  through  the  h-mph-channels;  and  (4)  by 
contiguity  from  neighboring  structures. 

I.  Infection  throtigh  the  blood  is  considered  rare.  The  pancreas 
is  not  situated  as  is  the  liver  in  relation  to  the  portal  circulation,  and 
thus  is  not  constantly  inundated  with  hordes  of  bacteria  from  the 
intestines  as  we  are  now  led  to  believe  is  the  case  with  the  liver  (see 
page  417).  The  pancreas  is  thus  almost  immune  from  infection  through 
its  venous  channels,  except  by  retrograde  embolism  in  portal  thrombosis; 
a  case,  possibly  of  this  nature,  was  reported  in  1885  by  Musser,  though 
it  is  not  impossible  that  there  was  here  an  ascending  sialodochitis. 
The  pancreas  occasionally  is  the  seat  of  pyemic  abscess,  as  in  the  case 
reported  by  Roddick  (1869)  and  as  in  one  patient  with  appendicitis, 


PATHOGENESIS    OF   INFECTIONS  615 

under  the  care  of  the  senior  author;  or  is  diseased  in  other  general 
infections;  indeed  the  experimental  and  clinical  facts  recently  adduced  in 
support  of  hematogenous  infection,  by  Abrami,  Richet  and  Saint-Girons 
(1910)  make  it  probable  that  this  source  is  less  rare  than  hitherto 
has  been  supposed.  Macaigne  (1894)  observed  a  case  of  pneumococcic 
peritonitis  with  an  abscess  of  the  pancreas  from  which  a  pure  culture 
of  the  pneumococcus  was  obtained;  and  though  he  expresses  the  con- 
viction that  the  infection  of  the  pancreas  was  received  by  way  of  its 
ducts,  it  seems  quite  as  likely  to  have  been  hematogenic.  S.  Phillips 
(1908)  observed  a  case  of  scarlet  fever  with  pancreatitis  and  parotitis; 
and  the  occurrence  of  lesions  in  the  pancreas  as  well  as  in  the  supra- 
renal glands,  during  the  course  of  scarlet  fever  has  been  carefully 
studied  by  Tixier  and  Troisier  (191 2).  The  association  of  epidemic 
parotitis  (mumps)  with  pancreatitis  is  row  well  recognized,  and  though 
Fitz  (1889)  wrote  that  "it  may  be  safely  stated  that  there  is  no  reason 
for  admitting  the  existence  of  a  metastatic  pancreatitis  secondary  to 
inflammation  of  the  parotid  gland,"  the  belief  is  now  very  general, 
and  we  believe  it  is  well  estabhshed  clinically,  that  such  an  affection 
does  occur;  but  the  pathogenesis  of  this  metastatic  pancreatitis  is 
no  more  easily  explained  than  the  similar  involvement  of  the  tes- 
ticles or  ovaries.  It  was  Schmackpeffer  who,  in  18 17,  first  called 
attention  to  the  fact  that  the  pancreas  might  be  involved  in  mumps. 
Gordon  Sharp  (1908)  points  out  that  pancreatitis  may  pi-ecede  as 
well  as  follow  the  parotitis.  Ordinarily  the  symptoms  of  acute  pan- 
creatitis occur  on  the  third  or  fourth  day  after  the  parotid  swelling 
has  reached  its  height;  and  the  parotid  may  undergo  resolution  so 
soon  as  the  abdominal  symptoms  appear.  Sharp  likewise  calls  at- 
tention to  the  fact  that  during  an  epidemic  one  patient  in  a  household 
or  in  an  infected  area  may  show  parotitis,  while  another  patient 
may  have  only  pancreatitis;  but  he  contends  that  both  are  due  to 
one  and  the  same  cause.  If  parotitis  occurs  in  the  course  of  pan- 
creatitis, it  seems  much  more  reasonable  to  suppose,  unless  there 
is  an  epidemic  of  the  disease,  that  the  infection  reaches  the  parotid 
along  its  duct,  from  the  mouth,  as  in  tj-phoid  fever,  and  as  occasionally 
observed  after  etherization. 

From  the  observations  of  Simonin  (1903),  pancreatitis  appears  to  be 
a  rare  complication  of  mumps;  in  652  cases  of  the  latter  disease  he 
carefully  examined  the  abdomen  for  signs  of  pancreatic  involvement, 
but  found  it  only  in  ten  cases  (1.53  per  cent.)  Other  observers, 
however,  have  found  it  much  more  prevalent  in  certain  epidemics, 
as  was  demonstrated  in  the  table  published  in  the  first  edition  of  this 


6l6  SURGERY  OF  THE  PANCREAS 

work.  This  table,  which  gave  all  the  cases  we  could  find,  up  to  that 
date,  of  pancreatic  symptoms  occurring  in  patients  with  mumps, 
indicated  that  6i  cases  were  on  record;  and  that  51  of  these  were  known 
to  have  occurred  in  a  total  of  789  cases  of  mumps,  or  an  incidedce  of 
6.5  per  cent.  So  far  as  is  known,  the  case  of  Lemoine  (1905)  is  the  only 
one  which  terminated  fatally.  In  Edgecombe's  patient  (1908)  the 
urine,  examined  by  Cammidge  himself,  gave  a  positive  "pancreatic 
reaction." 

In  this  connection  it  is  interesting  to  note  that  diabetes,  presumably 
of  pancreatic  origin,  has  occasionally  followed  the  mumps  (Harris, 
1899). 

Influenza,  syphilis,  luherculosis,  malaria,  typhoid  fever,  etc.,  are 
occasionally  accompanied  by  chronic  pancreatitis,  which  is  due  to  the 
local  action  of  the  infecting  organism  when  this  circulates  in  the  blood, 
or,  as  is  probably  more  often  the  case,  to  the  toxins  produced  by  the 
bacteria  which  are  localized  elsewhere  in  the  body.  Warthin  (1916) 
found  not  one  normal  pancreas  at  autopsies  on  150  syphilitics,  and 
believes  syphilis  is  the  most  common  cause  of  chronic  interstitial 
pancreatitis.  Sailer  and  Speese  (1908)  succeeded  in  producing  focal 
necroses  in  the  liver  and  pancreas  of  guinea-pigs  by  injecting  blood 
serum  from  dogs  affected  with  experimentally  induced  acute  pancreati- 
tis. Injections  of  normal  serum  had  no  such  effect.  It  was  also  found 
possible  to  produce  a  high  degree  of  immunity  by  gradually  increasing 
the  doses  of  the  toxic  serum.  Egdahl  (1907)  referred  to  cases  of  acute 
pancreatitis  following  or  associated  with  the  following  affections :  syphi- 
lis, typhoid  fever,  malaria,  emboli,  furunculosis,  bronchitis,  heart- 
disease,  pulmonary  tuberculosis,  and  appendicitis.  Hirschfeld  (1909) 
studied  in  some  detail  the  relation  of  general  infections  to  diseases  of  the 
pancreas. 

In  arteriosclerosis,  which  may  be  considered  an  intoxication,  if  not  a 
toxemia,  the  pancreas  is  quite  constantly  affected  by  a  chronic  indura- 
tive inflammation  (cirrhosis),  and  the  arteries  are  often  the  seat  of 
miliary  aneurisms  (Lancereaux,  1899),  ^  ^^.ct  which  sometimes  is  held 
to  explain  the  frequency  of  hemorrhagic  lesions  in  this  organ. 

Alcoholism  possibly  may  transmit  a  non-bacterial  inflamma- 
tion to  the  pancreas  through  the  blood  stream,  either  directly,  or, 
as  is  probably  much  less  frequently  the  case,  by  chronic  passive  con- 
gestion through  hepatic  cirrhosis.  It  is  taught  by  Opie  (1908)  that 
both  hepatic  and  pancreatic  cirrhosis  are  due  to  the  same  cause,  and 
that  the  pancreatic  condition  is  seldom  if  ever  caused  by  obstruction  of 
the  portal  circulation  alone.     Another  condition  in  which  the  pancreas 


INFECTION   THROUGH    THE    DUCTS  617 

is  quite  constantly  involved  in  a  cirrhotic  process  is  that  described  in 
1899  by  V.  Recklinghausen  as  hemachromaiosis,  which  in  its  later  stages 
frequently  is  accompanied  by  the  diabete  bronze  of  the  French. 

2.  Infection  through  the  Ducts. — It  is  usually  taught  that  in  the 
pancreas  infection  most  often  occurs  by  continuity  of  structure  upward 
from  the  duodenum,  through  the  papilla  of  Vater  and  along  the  duct 
of  Wirsung.  But  though  numerous  experiments,  which  will  be  men- 
tioned presently,  prove  that  this  avenue  of  infection  is  quite  possible, 
other  experiments  and  certain  anatomical  facts  tend  to  make  us  ques- 
tion its  frequent  occurrence. 

Opie  (1903)  found  that  the  valve-like  folds  within  the  diverticulum 
of  Vater  prevent  the  regurgitation  of  material  from  the  duodenum  into 
the  duct  of  Wirsung,  and  that  if,  after  death,  fluid  is  forced  under  con- 
siderable pressure  into  the  duodenum,  tied  above  and  below  the  pan- 
creas, none  enters  the  duct.  Archibald  (1919)  reports  that  he  tried  the 
experiment,  the  solution  being  under  a  pressure  of  1000  mm.  of  water 
for  an  hour;  but  none  entered  the  ducts.  Moreover,  in  only  live  out 
of  223  cases  examined  did  Truhart  (Bohm,  1904)  find  bacteria  present 
in  the  normal  duct  of  Wirsung;'  and  the  singular  freedom  of  the  duo- 
denum from  bacterial  life  has  frequently  been  pointed  out.  As  has 
been  seen  already  (page  417),  biliary  infection  usually  occurs  primarily 
through  the  portal  blood  stream,  being  thus  a  descending  infection  from 
the  liver;  and  infection  of  the  ducts,  unless  these  are  obstructed  by 
calculi,  does  not  occur  to  any  marked  degree  because  the  bile  is  more  or 
less  constantly  passing  through  them,  and  thus  clears  them  of  infectious 
material.  But  the  gall-bladder,  where  the  bile  is  prone  to  become  a 
stagnant  pool,  is  frequently  the  site  of  infection,  and  this  infection  is  to 
all  intents  and  purposes  primary  there,  though  really  having  its  origin 
in  the  infected  bile  secreted  by  the  liver.  Now  in  the  pancreas  there  is 
no  such  stagnant  pool  as  is  found  in  the  gall-bladder;  the  pancreatic 
juice  is  more  actively  bactericidal  than  the  bile  (Remedi,  1905);  and 
blood  infections  of  the  pancreas  are  rare;  rare  also,  therefore,  is  a 
descending  infection  of  the  pancreatic  duct. 

But  there  is  this  to  be  said  in  favor  of  the  occurrence  of  an  ascending 
infection  of  the  pancreatic  ducts — that  any  obstruction  to  the  outflow 
of  pancreatic  juice  will  predispose  it  to  infection,  and  may  make  quite 
possible  a  pancreatic  infection  arising  in  the  mildly  infectious  bile 
passing  through  the  ampulla  of  Vater.  Such  obstruction  of  the  duct 
of  Wirsung  frequently  occurs  in  the  case  of  gall-stones  impacted  in  the 

'  The  e.xistence  of  anaerobic  bacteria  in  the  normal  biliary  and  pancreatic  ducts  has  been 
emphasized  as  a  cause  of  infection  in  cases  of  obstruction  by  Gilbert  and  Lippmann  (1908). 


6l8  SURGERY  OF  THE  PANCREAS 

lower  end  of  the  common  bile-duct.  Besides  such  factors  as  these,  it 
must  not  be  overlooked  that  the  accessory  pancreatic  duct  (Santorini) 
must  sometimes  be  taken  into  consideration  as  a  possible  avenue  of 
infection.  It  is  claimed  by  Desjardins  (1905)  that,  while  the  normal 
current  of  pancreatic  juice  in  the  duct  of  Wirsung  flows  toward  the 
duodenum,  the  flow  in  the  duct  of  Santorini  is  indifferently  either 
toward  the  duodenum  or  away  from  it  toward  the  intraglandular 
anastomosis  of  the  two  ducts;  so  that  in  this  way,  he  asserts,  micro- 
organisms from  the  duodenum  easily  and  frequently  ascend  by  the  duct 
of  Santorini,  and  meeting 'the  outflowing  current  in  the  main  duct 
are  carried  back  through  the  head  of  the  pancreas,  thus  doubly  infecting 
the  area  enclosed  between  the  two  ducts.  This  area  has  been  named 
by  Desjardins  the  "triangle  of  infection."  This  theory  takes  little 
account  of  the  supposed  bactericidal  action  of  the  pancreatic  juice, 
or  of  the  relatively  mild  infectiousness  of  the  duodenal  contents;  and 
fails  to  explain  cases  of  pancreatic  infection  in  which  the  duct  of 
Santorini  is  not  patent,  or  does  not  anastomose  with  the  duct  of  Wir- 
sung. Schirmer  (1893)  found  the  duodenal  orifice  of  the  duct  of 
Santorini  permeable  in  only  a  little  over  half  of  the  cases  (about  100  in 
number)  examined  by  him.  In  only  forty-eight  out  of  100  specimens 
dissected  by  Opie,  was  the  duodenal  orifice  of  the  duct  of  Santorini 
permeable  to  injected  fluid,  while  in  forty-two  cases  its  duodenal  orifice 
was  closed,  the  duct  of  Santorini  appearing  merely  as  a  branch  of  the 
main  duct;  and  in  ten  cases  the  two  ducts  were  not  in  anastomosis 
at  all. 

But  even  if  we  acknowledge,  as  it  seems  we  are  bound  to  do, 
that  ascending  injection  of  the  pancreatic  duct  is  ra»e,  there  never- 
theless remain  experimental  and  chnical  proofs  that  disease  of  the 
pancreas  does  undoubtedly  arise  from  the  retrojection  of  bile  into  the 
pancreas,  from  its  chemical  action,  even  if  the  bile  is  not  actively 
infectious.  Opie's  much  quoted  case  (1901)  is  an  interesting  example: 
at  autopsy  the  cause  of  acute  pancreatitis  was  found  to  be  a  small 
biliary  calculus  lodged  at  the  duodenal  orifice  of  the  ampulla  of  Vater; 
the  calulus  was  so  small  that  it  did  not  obstruct  the  orifice  of  the  duct 
of  Wirsung,  but  by  occluding  the  common  outlet  of  this  duct  and  of  the 
common  bile-duct,  allowed  retrojection  of  bile  to  occur  into  the  pan- 
creatic duct.  Similar  results  have  been  obtained  experimentally  by 
Carnot  (1898),  Flexner  (1900),  and  several  other  investigators  (accounts 
of  whose  work  are  given  by  Flexner),  by  injecting  various  substances  di- 
rectly into  the  duct  of  Wirsung.  Flexner  showed  subsequently  (1906) 
that  when  bile  is  injected  into  the  pancreatic  duct,  it  is  the  bile-salts 


INFECTION   THKOUGH    THE    DUCTS  619 

which  are  the  destructive  agent,  and  that  the  more  colloid  material  the 
bile  contains  the  less  intense  is  the  inflammation  produced  by  it. 
Flexner  therefore,  suggested  that  as  in  chronic  inflammation  of  the 
biliary  passages  (as  in  cholelithiasis)  there  is  a  loss  of  diffusible  salts 
and  an  increase  of  colloid  material,  ascending  infection  of  the  pancreatic 
duct  should  in  such  cases  lead  to  chronic  rather  than  acute  pancreatitis; 
and  that  this  is  actually  the  case  will  be  pointed  out  in  a  subsequent 
section.  Nordmann  (1913)  found  if  he  closed  both  pancreatic  open- 
ings in  dogs,  and  injected  bacterial  cultures  into  the  gall-bladder, 
that  all  the  dogs  died  of  acute  pancreatitis ;  if  only  the  common  opening 
of  the  bile  and  pancreatic  ducts  was  closed,  no  pancreatitis  developed, 
as  the  pancreas  drained  itself  through  its  accessory  duct;  but  the  dogs 
died  of  cholangeitis. 

Archibald,  in  numerous  able  papers  since  1910,  has  maintained  the 
theory  of  the  " retrojection  of  bile"  as  the  most  rational  explanation  of 
the  pathogenesis  of  pancreatitis;  and  has  published  numerous  experi- 
mental researches  and  clinical  cases  which  lend  support  to  his  views. 
He  notes,  as  have  other  surgeons,  that  as  operative  experience  has  in- 
creased, so  pari  passu  have  increased  the  number  of  cases  of  pancreati- 
tis, acute  or  chronic,  in  which  no  gross  lesion  (calculi,  cholecystitis, 
etc.)  of  the  biliary  tract  could  be  demonstrated;  indicating  that 
neither  a  mere  descending  infection  nor  yet  the  impaction  of  a  calculus 
in  the  ampulla  of  Vater  was  a  sufficient  explanation  in  all  cases.  The 
explanation  which  Archibald  o'ffers  (1912,  1913,  1919)  is  a  spastic 
contraction  of  the  sphincter  known  by  the  name  of  Oddi  (1887)  sur- 
rounding the  duodenal  orifice  of  the  common  duct.  The  importance 
of  this  sphincter  was  scarcely  recognized  by  surgeons  until  Archibald 
began'calling  attention  to  it,  though  the  existence  of  the  sphincter  was 
well  known,  and  it  was  mentioned  in  our  first  edition  (1909,  Vol.  I, 
p.  39).  He  thinks  it  possible  that  this  spasticity  of  the  sphincter 
of  Oddi  may  be  aroused  by  hyperacidity  of  the  duodenal  contents; 
and  he  suggests  that  both  in  alcohohc  individuals  and  in  those  with 
duodenal  ulcer  (in  both  of  which  classes  pancreatitis  is  rather  frequent), 
the  duodenal  contents  may  remain  acid  for  a  long  time.  Chemical 
researches  (1920)  under  his  direction,  indicate  that  in  infected  bile  the 
proportion  of  bile  salts  (the  active  agent  in  producing  pancreatitis)  to 
mucin  is  increased  from  six  to  twelve  fold  over  that  present  in  normal 
bile. 

Experimentally  chronic  pancreatitis  has  been  produced  (a)  by 
obstruction  of  the  pancreatic  duct  by  a  ligature;  {h)  by  injecting  into 
the  pancreatic  duct  attenuated  cultures  of  various  micro-organisms. 


620  SURGERY  OF  THE  PANCREAS 

modified  bile,  etc.;  (c)  Carnot  produced  chronic  pancreatitis  from  an 
ascending  duodenal  infection  by  the  ingenious  plan  of  fixing  a  thread 
in  the  duct  of  Wirsung  and  carrying  it  through  the  ampulla  of  Vater 
into  the  intestine,  where  it  was  allowed  to  hang  free.  But  such  experi- 
ments as  these,  as  very  justly  remarked  by  ]Maugeret  (1908),  imply 
such  actual  traumatism  to  the  pancreas  as  to  make  the  interpretation 
of  the  results  obtained  very  hazardous.  Whether  obstruction  alone  is 
an  efiicient  factor  in  producing  pancreatitis  is  a  question  very  diffi- 
cult to  decide,  because  as  soon  as  the  pancreatic  secretion  becomes 
stagnated  the  virulence  of  the  anaerobic  bacteria  (which,  as  already 
remarked,  may  be  considered  normal  inhabitants  of  the  ampulla  of 
Vater  and  lower  pancreatic  ducts)  is  markedly  increased  and  the 
subsequent  changes  may  be  attributable  largely  to  their  action.  As 
Ebner  (1907)  tersely  expressed  it,  the  results  of  obstruction  are  first 
mechanical,  then  chemical,  and  then  bacterial. 

Intestinal  parasites  have  been  observed  occasionally  in  the  duct  of 
Wirsung.  according  to  Lieutaud  and  others  (cited  by  Carnot,  1908). 
Muroya  (191 2)  found  ascarides  encapsulated  in  the  pancreas. 

Infection  through  the  Lymphatics. — Largely  by  exclusion,  appar- 
ently, investigators  have  been  led  to  believe  that  chronic  infection 
of  the  pancreas  in  a  majority  of  cases  is  due  to  invasion  of  its  sub- 
stance by  way  of  the  lymph-channels.  This  view  is  held  by  Prof. 
ThiroloLx,  and  was  developed  and  ably  supported  by  his  pupil  Maugcret 
(1908),  who  urges  that  as  the  efferent  lymphatics  from  the  gall-bladder 
and  those  from  the  pancreas  anastomose  around  the  head  of  the  pan- 
creas, this  part  of  the  gland  is  in  this  manner  easily  invaded  directly 
from  the  lymph-nodes  or  lymph-channels.  For  this  pathological 
state  we  adopted  (1912)  the  term  pancreaticlymphangeitis,  proposed  by 
Arnsperger  (1911).  It  is  a  condition  which  precedes  true  interstitial 
pancreatitis,  and  which  is  curable  by  proper  surgical  treatment.  Ac- 
cording to  this  view,  which  we  believe  to  be  correct  for  the  great  ma- 
jority of  cases  previously  classed  together  as  chronic  pancreatitis,  it  is 
still  the  infected  bile  and  the  diseased  gall-bladder  which  must  be 
incriminated  as  the  "fans  et  origo  viali,"  though  we  have  also  pointed 
out  the  possibiUty  of  pancreatic  lymphangeitis  occurring  as  the  result 
of  duodenal  and  even  gastric  lesions  (page  663).  It  has  also  been 
suggested  that  though  an  ascending  catarrhal  infection  along  the  pan- 
creatic duct  is  rare,  yet  micro-organisms  may  and  frequently  do  travel 
up  in  the  walls  of  the  pancreatic  ducts,  as  they  are  known  to  do  up  the 
walls  of  the  choledochus,  even  after  this  has  been  Hgated.  The  common 
bile-duct  is  imbedded  in  the  head  of  the  pancreas  in  from  60  to  95  per 


PATHOGENESIS   OF   CALCULI  62 1 

cent,  of  cases  (Helly,  1898,  Ebner,  1907,  Kehr,  1909),  so  that  any 
affection  which  injures  the  walls  of  the  choledochus  will  be  very  liable  to 
spread  to  the  surrounding  pancreatic  tissue  through  the  lymphatics. 
On  such  grounds  has  been  explained  the  very  frequent  occurrence  of 
chronic  pancreatitis  as  a  sequel  of  common  duct  calculus;  but  Maugeret 
contends  that  this  frequent  association  of  pancreatitis  with  common 
duct  calculus  is  susceptible  of  another  interpretation,  namely,  that  the 
calculus  is  arrested  in  the  common  duct  by  the  narrowing  of  this  channel 
consequent  upon  the  previous  existence  of  a  pancreatitis,  which  in  this 
as  in  other  cases  is  caused  not  by  a  calculus  in  the  common  duct,  but  by 
infection  in  the  gall-bladder;  and  she  further  calls  attention  to  the  ex- 
treme rarity  of  such  local  lesions  in  the  common  duct  (suppurative  or 
ulcerative  angeiocholitis)  as  could  give  rise  to  pancreatitis  by  con- 
tiguity. 

The  subject  of  pancreatic  lymphangcilis  is  discussed  at  page  659. 

4.  Infection  by  contiguity  is  of  infrequent  occurrence,  unless  pro- 
pagation of  infection  from  the  walls  of  the  common  duct,  which  has 
just  been  mentioned,  is  to  be  included  here.  The  stomach  is  the  organ 
which  is  most  often  at  fault  in  these  cases,  ulcers  perforating  into, 
and  cancers  becoming  densely  adherent  to  the  pancreas,  and  setting  up 
a  localized  inflammatory  reaction.  Splenic  abscess  may  involve  the 
tail  of  the  pancreas;  pyonephrosis,  on  either  side,  but  usually  the  left, 
sometimes  has  transmitted  its  infection  to  the  adjacent  portion  of  the 
pancreas;  and  the  head  of  the  pancreas  is  not  seldom  invaded  by  tuber- 
culosis or  other  infection  localized  in  the  subpyloric  or  retropancreatic 
lymph-nodes. 

Pancreatic  Calculi. — Although  concretions  in  the  pancreas  were 
described  (de  Graaf,  166.3)  long  before  cysts  (Engle,  1841),  pancreatic 
apoplexy  (Spiess,  1866),  or  fat  necrosis  (Balser,  1879),  they  occupy, 
when  compared  with  biliary  calculi,  a  very  insignificant  place  in  the 
surgery  of  the  pancreas.  Opie  found  only  two  instances  of  pancreatic 
calculi  among  1500  autopsies,  and  thinks  that  the  figures  of  Giudice- 
andrea  (two  in  122  autospises)  much  exaggerate  their  frequency. 
Lazarus,  in  1904,  was  able  to  find  records  of  only  eighty  cases  of 
pancreatic  calculi.  Einhorn  (1916)  has  observed  two  cases,  and  a  few 
additional  cases  are  on  record. 

Pancreatic  calculi  occur  nearly  five  times  as  often  in  men  as  in 
women,  according  to  Lazarus,  who  found  the  sex  mentioned  in  fifty- 
seven  cases,  forty-seven  out  of  which  were  found  in  men.  Lazarus 
points  out  that  both  infection  and  stasis  of  the  secretion  are  necessary 
for  the  formation  of  pancreatic  concretions.     Guidiceandrea  (1896) 


62  2  SURGERY  OF  THE  PANCREAS 

found  bacteria  in  the  center  of  pancreatic  calculi,  and  it  is  interesting 
to  note  that  the  same  experience  in  regard  to  salivary  calculi,  which 
closely  resemble  those  of  the  pancreas,  has  been  recorded  by  Galippe 

(1893)- 

Pancreatic  calculi  usually  are  multiple,  the  largest  being  near 
the  orifice  of  the  main  duct,  and  the  others,  perhaps  hundreds  in 
number,  scattered  along  its  entire  length  and  even  in  the  finest  branches 
of  the  pancreatic  ducts  (Fig.  158).  Occasionally  star-shaped  or  branched 
calculi  are  found.  The  largest  stone  ever  recorded,  according  to  Lazarus, 
was  that  of  Schupmann,  which  measured  J-2  inch  by  iXj,  inches,  and 
weighed,  according  to  Villar  (1905),  200  grams.  Pancreatic  calculi  are 
composed  almost  entirel}'  of  calcium  carbonate  or  calcium  phosphate, 
are  not  crystalline,  and,  because  of  the  narrowness  of  the  pancreatic 


If 


Fig.    158. — Pancreatic    Calculi.     {From    a    Specimen    in   the    Museutn   of  the  Lankenau 

Hospital.) 

ducts,  thej^  are  very  rarely  faceted  except  at  their  ends.  Usually  they 
are  white.  Solitary  stones,  which  are  quite  rare  (four  among  twenty-two 
cases,  Lazarus) ,  are  more  apt  to  be  composed  of  oxalates.  The  nucleus 
of  pancreatic  calculi  probably  is  derived  from  the  interaction  of  the 
desquamated  epithelium  lining  the  ducts  with  the  secretion  which 
has  been  modified  as  the  result  of  infection;  the  result  of  this  inter- 
action is  the  precipitation  of  inorganic  salts  (which  are  not  found  in 
normal  pancreatic  juice) ;  and  new  layers  are  formed  as  in  other  calculi 
(biliary,  renal)  by  the  deposit  of  calcium  or  magnesium  phosphates 
and  carbonates,  or  even  of  cholesterin. 

While  pancreatic  calculi  are  in  the  first  instance  the  result  of  disease 
of  the  pancreas,  they  become  when  once  formed  the  cause  of  further 
structural  alterations.  By  damming  up  the  pancreatic  secretion  they 
lead  in  time  to  a  condition  of  very  marked  sclerosis  of  the  gland.  Of 
the  eighty  cases  of  pancreatic  calculi  collected  b}^  Lazarus,  thirty-six 
(45  per  cent.)  presented  also  diabetes,  or  at  least  glycosuria. 


PANCREATIC   DIABETES  623 

Carcinoma  of  the  pancreas,  however,  rarely  is  associated  with  the 
formation  of  stones.  Like  calculi  of  other  organs,  those  of  the  pancreas 
occasionally  ulcerate  their  way  into  other  viscera,  or  even  into  the 
peritoneal  cavity.  Galliard  (1880)  recorded  the  case  of  a  patient  who 
was  found  at  autopsy  to  have  a  pancreato-gastric  fistula,  one  pancreatic 
calculus  lying  free  in  the  stomach,  and  others  being  still  within  the 
pancreas.  In  Clayton's  patient  (1839),  who  died  with  symptoms 
of  internal  hemorrhage,  a  calculus  was  found  to  have  ulcerated  out  of  the 
pancreas  into  the  general  peritoneal  cavity,  opening  a  blood-vessel; 
other  calculi  were  found  within  the  ducts  of  the  pancreas. 

According  to  Desjardins  (1905),  the  rarity  of  pancreatic  calculi  and 
the  frequency  of  gall-stones  are  to  be  explained  by  inherent  differences 
between  the  biliary  and  the  pancreatic  systems.  He  holds,  and  Quenu 
and  Duval  (1905)  agree  with  him,  that  the  same  infection  arising  in 
the  intestine  and  travehng  up  the  bile  and  pancreatic  ducts  will  in  the 
former  situation  induce  a  stone-forming  catarrh,  but  in  the  pancreas 
will  cause  a  chronic  interstitial  inflammation. 

The  symptoms,  diagnosis  and  treatment  of  pancreatic  calcuU 
are  considered  at  page  685. 

Pancreatic  Diabetes. — The  connection  between  pancreatic  disease 
and  diabetes  has  been  recognized  since  the  time  of  Cawley  (1788), 
though  this  observer  distinctly  stated  his  opinion  that  the  numerous 
calculi  which  were  found  in  the  pancreas  of  his  patient  were  the  result, 
not  the  cause,  of  the  diabetes.  In  1858  Claude  Bernard  discovered 
that  puncture  of  the  floor  of  the  fourth  ventricle  caused  glycosuria, 
and  for  years  the  nervous  theory  of  the  origin  of  diabetes  seemed  to 
rule  the  medical  world.  It  was  not  until  1877  that  the  theory  of 
pancreatic  diabetes  as  a  clinical  entity  was  formally  propounded  by 
Lanceraux;  and  the  theory  was  first  firmly  established  as  fact  by  the 
experimental  work  of  v.  Mering  and  Minkowski,  in  1889.  Of  late 
years  the  number  of  cases  of  diabetes,  in  which  no  lesions  are  to  be 
found  in  the  pancreas,  appears  to  be  steadily  decreasing.  This  in- 
crease in  the  number  of  cases  of  pancreatic  diabetes  is  due  largely 
to  more  careful  examination,  especially  to  microscopical  study  of 
the  pancreas  post-morten.  According  to  Cammidge  (1908),  some 
observers  claim  that  all  cases  of  diabetes  are  pancreatic  in  origin, 
but  this  gland  was  proved  at  fault  only  in  about  88  per  cent,  of  the 
288  cases  of  diabetes  mellitus  collected  by  Opie  in  1908.  In  6  cases 
of  diabetes,  where  the  pancreas  was  examined  at  autopsy  by  Warthin 
(1913),  the  patients  were  syphilitic,  and  he  regarded  the  pancreatic 
lesions  as  being  syphiHtic  in  origin. 


624  SURGERY  OF  THE  PANCREAS 

The  changes  in  the  pancreas  which  lead  to  diabetes  are  believed 
to  be  confined  to  the  islands  of  Langerhans.  The  secreting  paren- 
chyma or  the  interstitial  tissue  of  the  gland  may  be  very  extensively 
diseased,  even  almost  entirely  destroyed;  yet  it  seems  an  established 
fact  that  so  long  as  a  certain  proportion  of  the  islands  of  Langerhans 
remains  intact,  glycosuria  does  not  occur.  It  is,  moreover,  apparently 
proved  that  the  development  of  glycosuria  in  disease  of  the  pancreas 
is  to  be  attributed  to  interference  with  the  internal  secretion  of  the 
gland;  for  it  has  been  found  (Minkowski),  if  a  portion  of  the  pancreas 
is  successfully  transplanted  into  the  subcutaneous  tissues,  being 
severed  from  all  its  nervous  connections,  that  the  entire  portion  remain- 
ing in  the  abdomen  may  be  removed  and  that  glycosuria  will  not 
develop  until  the  transplanted  portion  also  is  removed,  or  until  it 
becomes  atrophic. 

It  is  evident,  therefore,  that  the  cause  of  glycosuria  and  of  the 
accumulation  of  sugar  in  the  blood  is  dependent  upon  some  influence 
which  the  pancreas  exerts  by  way  of  the  blood  or  lymph  stream.  Two 
theories  are  proposed  to  explain  the  means  by  which  these  changes 
are  brought  about:  (i)  The  auto-intoxication  theory,  by  which  it  is 
assumed  (Robson  and  Cammidge,  1908)  "that  the  cells  of  the  pancreas 
normally  destroy,  or  modify,  some  toxic  substance,  produced  in  other 
parts  of  the  body,  which  interferes  with  the  utilization  of  sugar  by 
the  tissues;"  (2)  the  theory  that  the  pancreas  contributes  some  activator 
substance  to  the  circulation,  which  assists  a  glycolytic  enzyme  pro- 
duced by  other  tissues  of  the  body.  The  second  theory  is  that  which 
has  received  most  support  of  late. 

The  relation  of  the  adrenals,  and  of  the  hypophysis  cerebri  to  pan- 
creatic activity  has  been  too  little  studied,  and  is  still  much  too  obscure 
a  subject  for  any  authoritative  statement  to  be  made  at  this  time. 
It  is  perhaps  sufficient  to  recall  the  existence  of  cases  of  pancreatic 
infantilism;  to  note  that  a  diminished  function  of  the  anterior  part 
of  the  hypophysis  is  productive  of  similar  changes  (von  Eiselsberg, 
1 910);  that  certain  cases  of  acromegaly  {hyperpituitarism)  have  been 
associated  with  diabetes  (Opie) ;  and  that  the  local  action  of  adrenalin 
upon  the  pancreas  causes  temporary  glycosuria  (Robson  and  Cam- 
midge) ;  while  the  external  secretion  of  the  pancreas  appears  to  be 
stimulated  by  the  administration  of  adrenalin  hypodermically  (Pem- 
berton  and  Sweet,  19 10).  Of  clinical  interest  is  the  case  reported 
by  Lavenson  (1908),  in  which  sjTnptoms  supposed  to  be  due  to  acute 
pancreatitis  were  found  at  autopsy  to  have  been  caused  by  hemorrhage 
into  the  adrenals.     Lowi's  test  (1908)  for  pancreatic  disease  (mydriasis 


PANCREATIC    DIABETES 


625 


from  instillation  of  adrenalin  into  the  eye) ,  though  by  no  means  authori- 
tative, is  another  evidence  of  the  little  understood  relation  of  the 
pancreas  and  the  adrenals. 

In  an  interesting  study  of  "The  Theory  and  Treatment  of 
Diabetes,"  von  Noorden  (1913)  has  endeavored  to  represent  graph- 
ically the  co-relationship  of  Pancreas,  Liver,  Central  Nervous  System 
and  the  Ductless  Glands  (Fig.  159).     He  says: 

"The  manufactory  for  sugar  is  the  liver,  and  the  liver  cells  con- 
stitute the  working  department. 

n.ijmd  Gland  Parat/ii/md  Glands 

antralliemSystm  ^ -^  V       ^^/fl/Z/oplipis 

Tissues 


Pig.  159- — Diagram  to  Explain  the  Modern  Theory  of  Diabetes,     (von  Noorden.) 

"The  important  claims  that  determine  the  amount  of  the  sugar 
production  arrive  from  other  organs  and  tissues,  especially  from 
the  muscles  (path  I).  The  greater  the  consumption  of  sugar  the 
stronger  will  be  the  claiming  impulse,  and  an  amount  of  sugar  suffi- 
cient to  meet  the  demand  will  pass  into  the  blood  (path  II).  This 
is  normally  the  only  influence  which  induces  the  liver  to  raise  its 
output. 

"However,  along  path  III  stimuli  will  also  pass.  This  path  repre- 
sents the  blood  streaming  into  the  liver  from  the  intestinal  wall, 
and  carrying  carbohydrates  and  the  products  of  protein  digestion. 
The  quantity  of  these  materials  varies  according  to  the  type  and 
composition  of  the  food.  So  long  as  the  manufacture  of  sugar  is  well 
under  control  the  effect  of  this  form  of  stimulus  is  not  to  induce  a 
liberal  outpuoring  of  sugar  into  the  general  blood  stream,  but  to  form 
glycogen.  This  glycogen  is  then  stored  until  it  is  reconverted  into  sugar 
at  the  request  of  the  tissues,  and  travels  along  path  II  to  the  muscles, 
etc. 

40 


626  SURGERY  OF  THE  PANCREAS 

"In  order  to  maintain  the  excitability  of  the  sugar  manufactories 
at  the  proper  intensity  the  two  controlling  factors  come  into  play. 
The  pancreas,  which  depresses  the  excitability,  sends  its  secretion  along 
path  B,  while  the  suprarenals,  which  increase  the  excitabiUty,  distribute 
their  secretion  along  path  A.  This  conjoined  action  serves  to  keep  the 
process  in  equilibrium. 

"Both  these  controlling  glands  are  in  turn  influenced  by  other 
organs — the  pancreas  through  the  thyroid  gland  path  (b),  and  the 
suprarenal  through  the  nerve  paths  (a).  The  diagram  shows  still 
other  inliuences  (paths  b'  and  b-);  their  existence  is  most  probable, 
but  their  origin  is  undetermined.  They  seem  to  be  subordinate  in 
importance  and  action." 

General  Diagnostic  Consider.a.tions 

Though  disease  of  the  pancreas  is  now  recognized  as  not  very 
rare,  and  the  contention  of  Robson,  that  its  diagnosis  usually  is  possible 
is  very  generally  accepted  as  true;  it  is  nevertheless  a  fact,  owing  to 
the  deep  situation  of  the  pancreas,  and  its  close  anatomical  and  physiolog- 
ical relations  with  surrounding  organs,  that  such  diagnosis  frequently 
is  difl&cult,  and  that  pancreatic  lesions  often  escape  even  acute 
observation. 

The  pancreas  has  both  digestive  and  metabolic  functions,  the  dis- 
turbance of  which  by  disease  causes  more  or  less  definite  symptoms; 
and  there  are  certain  physical  signs  which  usually  may  be  elicited  in 
cases  of  pancreatic  disease. 

Pancreatic  Insufficiency. — If  all  diseases  of  the  pancreas  were 
attended  bj'  obstruction  to  the  outflow  of  its  secretions  into  the  duode- 
num, the  "diagnosis  could  readily  be  made  by  means  of  the  duodenal 
tube  (Einhorn,  Rehfuss)  and  the  fractional  analysis  of  the  duodenal 
contents  obtained  by  its  means.  This  remains  the  best  means  of 
diagnosis  whenever  it  is  available  and  whenever  there  is  complete 
insufficiency  of  the  external  secretion  of  the  pancreas.  Since  the 
introduction  of  this  method  the  elaborate  methods  (mentioned  in 
our  first  edition),  for  determination  of  the  presence  of  the  pancreatic 
ferments  in  the  feces,  have  lost  most  of  their  interest;  and  only  a 
brief  account  of  them  is  retained  in  the  present  volume. 

Digestive  Symptoms. — It  is  well  known  that  the  digestive  functions 
of  the  pancreas  may  be  partiallj-  assumed  by  other  organs.  Possibly 
if  the  pancreas  could  be  removed  piecemeal,  destroying  its  functions 
one  by  one  in  very  gradual  stages,  the  loss  of  its  secretions  might  be 


GENERAL   DIAGNOSTIC   CONSIDERATIONS  627 

entirely  supplied  by  compensatory  action  of  the  salivary  glands, 
the  gastric  and  the  intestinal  juices.  The  amylolytic  function  of  the 
pancreas  is  supplemented  by  the  saliva;  the  tryptic  function  is  the 
same  as  that  of  the  pepsin  of  the  gastric  juice;  and  the  intestinal 
juices  and  bacteria,  aided  by  the  bile,  are  capable  of  caring  for  a  large 
part  of  the  ingested  fat.  But  when  disease  attacks  the  pancreas,  the 
destruction  of.  its  physiological  functions  often  takes  place  so  suddenly 
that  very  pronounced  and  definite  symptoms  are  produced.  Chief 
among  these  are  steatorrhea,  and  azoiorrhea;  others  are  sialorrhea, 
dyspepsia  (a  vague  term),  emaciation,  nausea,  vomiting,  etc.  The 
administration  of  pancreatic  extract,  pancreatin,  etc.,  as  a  means 
of  obviating  these  symptoms,  was  used  as  a  diagnostic  test  by  Salomon 
(1908)  and  others. 

Steatorrhea. — An  excess  of  fat  m  the  feces  was  first  recognized 
in  1820  by  Kuntzmann  as  due  to  pancreatic  disease. 

The  excess  of  the  fat  in  the  feces  may  be  evident  to  the  most  casual 
observation,  or  may  be  demonstrable  only  by  the  microscope.  In 
well-marked  cases  of  steatorrhea  the  passages  are  bulky,  of  a  silver, 
gray,  or  asbestos-like  color;  and  the  fat  may  float  on  the  surface  of  the 
fluid  mass  Uke  oil  droplets  or  particles  of  butter.  ■  Such  passages 
have  been  known  occasionally  to  occur  in  health,  after  the  ingestion 
of  abnormal  quantities  of  fatty  food,  as  individuals  differ  in  their 
ability  to  digest  fats;  and  diminution  of  the  secretion  of  bile,  diarrhea, 
caseation  of  the  mesenteric  lymph-nodes,  and  other  intestinal  derange- 
ments, as  well  as  pancreatic  disease,  may  give  rise  to  this   symptom. 

Azotorrhea. — The  presence  in  the  feces  of  undigested  proteid 
material  was  first  recognized  as  a  symptom  of  pancreatic  disease 
by  Fles,  in  1864.  If  gastric  digestion  be  deficient,  the  meat  fibres  will 
not  be  separated  from  each  other,  and  the  tr3'psin  of  the  pancreatic 
juice  will  be  able  to  act  only  on  the  surface  of  the  meat  bundles. 

Schmidt  (1908)  observed  that  a  safer  test  than  mere  digestion  of 
the  meat  fibres  was  the  destruction  of  the  nuclei  of  the  muscle  cells, 
since  these  are  digested  only  by  the  pancreatic  juice;  his  test  consists 
in  feeding  to  patients,  suspected  of  having  pancreatic  disease,  small 
cubes  of  beef  enclosed  in  little  silk  bags;  these  bags  are  readily  re- 
covered from  the  feces,  and  their  contents  are  examined  microscopically 
to  determine  whether  by  penetration  of  pancreatic  juice  the  muscle- 
cell  nuclei  have  been  destroyed. 

Mailer's  test,  to  determine  the  presence  of  a  proteolytic  ferment 
(tr^^psin)  in  the  feces,  is  described  by  Lyle  (1910) :  after  the  administra- 
tion of  a  test-meal,  and  suitable  preparation  of  the  fecal  mass,  small 


628  SURGERY  OF  THE  PANCREAS 

drops  of  the  latter  are  plated  on  a  Petri  dish  of  coagulated  blood  serum, 
and  this  is  incubated;  if  a  proteolytic  ferment  is  present,  small  depress- 
sions  are  produced  in  the  blood  serum  wherever  the  fecal  drops  have 
been  placed. 

Salili's  test  (1898,  iqo2)  for  the  efficiency  of  proteid  digestion 
depends  on  the  fact  that  gelatin  capsules  hardened  in  formol  resist 
gastric  digestion  for  twelve  hours  or  more,  but  are  rapidly  digested 
by  pancreatic  juice.  Bj-  administering  such  capsules  filled  with 
iodoform  the  fact  of  their  disintegration  can  be  proved  by  finding 
iodine  in  the  urine  or  saliva;  the  reaction  appears  in  health  in  from 
four  to  eight  hours,  and  if  there  is  no  marked  loss  of  gastric  motility 
a  delayed  reaction  indicates  impairment  of  pancreatic  function.  The 
test  is  by  no  means  accurate,  but  may  sometimes  aid  in  making  a 
diagnosis. 

Salomon's  test  (1908)  depends  on  the  fact  noted  in  i8g8  by  Deucher, 
that  lecithin  is  present  in  unusual  quantities  in  the  feces  of  patients 
with  pancreatic  disease.  Salomon  found  that  in  patients  with  pan- 
creatic disease  on  an  egg  diet  from  0.4  to  1.2  gram  of  lecithin  are 
excreted  in  the  ffeces  daily;  whereas  if  the  pancreas  is  normal,  never 
more  than  o.i  gram  is  excreted.  He  states  that  in  uncomplicated 
cases  of  biliary  obstruction  Jurgensen  found  the  quantity  varied  dailj- 
from  0.1  to  0.4  grams.  Salomon  also  claims  that  patients  with 
pancreatic  disease  who  are  fed  oh  v.  Xoorden's  oatmeal  diet  have 
tvpical  "butter  stools." 

Carbohydrate  Digestion. — Fedeli  and  Romanelli  (1909)  described 
a  test  for  the  determination  of  the  functional  activity  of  the  pancreas, 
which  they  found  was  quite  as  accurate  as  Miiller's  test:  their  test 
is  based  upon  the  fact,  proved  by  Roger  and  Simon,  that  saliva  is 
inhibited  by  the  gastric  juice  but  reactivated  by  the  pancreatic  juice 
if  in  an  alkaline  medium.  By  mixing  a  certain  portion  of  the  patient's 
saliva  with  gastric  juice  (or  HCl)  and  an  indicator  (carbohydrate), 
and  then  rendering  the  mixture  alkaline,  the  presence  of  pancreatic 
ferment  in  the  feces  is  shown  by  its  reactivating  effect  on  the  saliva, 
which  digests  the  carbohydrate  indicator  when  feces  and  saliva  are 
mixed. 

The  presence  of  stercobilin  in  the  feces  indicates  that  there  is  not 
complete  obstruction  to  the  discharge  of  bile  into  the  intestines. 
Robson  and  Cammidge  (1907)  found  that  it  is  entirely  absent  or 
present  in  only  verj-  faint  traces  in  cases  of  carcinoma  of  the  head 
of  the  pancreas,  where  biliary  obstruction  usually  is  complete  at  the 
time  these  patients  come  under  the  surgeon's  observation;  whereas 


GENERAL   DIAGNOSTIC   CONSIDERATIONS  629 

in  cases  of  obstructive  jaundice  due  to.  other  causes  (chronic  pancreati- 
tis, common  duct  cholelithiasis)  the  obstruction  is  rarely  absolute, 
and  a  distinct  though  often  subnormal  reaction  for  stercobilin  may 
be  obtained.  As  previously  remarked,  it  is  much  simpler  and  very 
much  more  accurate,  at  the  present  day,  to  examine  the  patient's 
duodenal  contents. 

Other  matters  in  the  patient's  stools  may  call  attention  to  the 
pancreas  as  the  seat  of  the  disease.  While  there  is  nothing  pathogno- 
monic about  blood  or  pus  in  the  motions,^  yet  the  periodic  discharge  of 
saliva-like  fluid,  which  has  been  noted  in  some  cases  of  pancreatic 
cysts,  or  the  passage  of  pancreatic  calculi,  could  scarcely  fail  to  arrest 
the  attention  of  both  patient  and  surgeon.  Chiari's  and  Trafeyer's 
patients  (1880)  passed  a  gangrenous  pancreas  by  rectum. 

Sialorrhea  Pancreatica. — Under  this  name  is  described  an  in- 
creased flow  of  saliva  which  has  been  observed  in  a  few  cases  of 
pancreatic  disease,  and  which  is  regarded  by  Robson  and  Cammidge 
as  significant  of  etiforts  at  compensation;  in  one  of  their  patients  trouble- 
some salivation  "ceased  in  a  most  striking  manner  within  forty-eight 
hours  after  he  had  been  operated  on  for  chronic  pancreatitis."  Carnot 
(1908)  referred  to  other  cases  recorded  by  Battersby,  Ludolph,  Holz- 
mann,  Caparelli,  and  Guidiceandrea. 

Dyspepsia  due  to  pancreatic  disease  is  difficult  to  differentiate 
from  those  forms  caused  by  biliary  or  gastric  affections.  Anorexia 
is  more  marked  in  gastric  affections.  Loss  of  weight  in  spite  of  in- 
gestion of  nearly  normal  amounts  of  food  frequently  characterizes 
pancreatic  disease.  Pain  is  less  acute  than  in  gastric  dyspepsia, 
and    attacks    of  colic  much  less  usual  than  in  gall-bladder  disease. 

Emaciation,  as  already  noted,  is  often  a  prominent  and  highly  sug- 
gestive symptom  of  disease  of  the  pancreas.  The  loss  of  flesh  is  rapid, 
persistent,  and  very  generally  observed  by  both  patient  and  physician. 

Metabolic  Symptoms.  Glycosuria. — As  was  pointed  out  in  the 
section  on  pancreatic  diabetes,  this  condition  is  associated  with 
change  in  the  islands  of  Langerhans,  and  occurs  only  when  their 
destruction  is  very  widespread;  moreover,  pancreatic  diabetes  may  be 
unaccompanied  by  any  symptoms  of  impairment  of  the  external 
secretion  of  the  pancreas.  Glycosuria,  therefore,  is  not  a  frequent 
symptom  of  such  pancreatic  lesions  as  have  interest  for  the  surgeon; 
it  usually  indicates  a  very  advanced  lesion,  which  is  most  frequently 
chronic  interstitial  pancreatitis  of  the  interlobular  type.  Interacinar 
pancreatitis,  though  producing  glycosuria  much  sooner,  is  a  much 
rarer  affection. 


630  SURGERY  OF  THE  PANCREAS 

Dextrose  is  the  sugar  usually  found  in  the  urine  of  pancreatic 
diabetes,   but  maltose   and   even   pentose   occasionally   are   present. 

Alimentary  Glycosuria. — Even  though  the  diet  of  a  health}-  indi- 
vidual contains  a  great  excess  of  sugar,  it  is  only  ver>-  exceptionally 
that  glycosuria  occurs  during  the  process  of  digestion.  But  this 
alimentary  glycosuria  is  much  more  apt  to  occur,  and  may  be  a  constant 
phenomenon,  if  there  is  serious  disease  of  the  pancreas.  It  was  found 
by  Wille  (1899),  after  whom  the  test  frequently  is  named,  that  in  about 
65  per  cent,  of  cases  of  alimentary  glycosuria  there  is  serious  disease  of 
the  pancreas.  Dextrose  (fruit  sugar)  is  better  for  the  test  than  cane 
sugar:  100  grams  of  dextrose  are  given  in  a  half  pint  of  water  on  the 
fasting  stomach,  and  the  urine  is  examined  two  or  three  hours  later. 

Opie  (1908)  succeeded  in  one  case  in  demonstrating  the  presence 
of  a  fat-splitting  ferment  in  the  urine;  Hewlett  (1904)  had  found  a  similar 
ferment  in  the  urine  of  dogs  for  a  period  of  from  three  to  five  days  after 
experimental  injuries  of  the  pancreas. 

Wohlgemuth  and  Noguchi  (191 2)  found  in  experiments  on  dogs, 
after  contusion  of  the  pancreas,  that  diastase  was  found  in  hath  blood  and 
urine.  They  think  the  test  should  be  even  more  accurate  in"  man 
than  in  the  dog,  and  that  diastase  should  appear  promptly  in  every 
case  of  pancreatic  lesion. 

Physical  Signs. — Inspection  may  show  emaciation,  which,  if  of 
rapid  occurrence,  in  connection  with  digestive  symptoms,  is  always 
suggestive  of  pancreatic  disease.  Jaundice  is  another  physical  sign 
very  evident  when  it  occurs,  but  by  no  means  so  frequent  in  pancreatic 
disease  as  the  relation  of  bihary  lesions  to  the  latter  might  lead  one  to 
expect.  The  occurrence  of  jaundice  depends  upon  the  relation  of  the 
common  bile-duct  to  the  head  of  the  pancreas;  and  Robson  and  Cam- 
midge  call  attention  to  the  coincidence  of  their  figures  with  Helly's 
anatomical  investigations:  as  was  stated  at  page  621,  Helly  found  the 
common  duct  embedded  in  pancreatic  tissue  in  62  per  cent,  of  cases;  and 
Robson  and  Cammidge  found  bile-pigments  in  the  urine  of  62  per  cent, 
of  those  cases  of  chronic  pancreatitis  which  were  associated  Math  chole- 
lithiasis. The  induration  of  the  pancreas  may  be  sufl&cient  to  obstruct 
the  outflow  of  bile  even  if  no  gall-stones  are  present.  Robson  and 
Cammidge  observed  jaundice  in  16  per  cent,  of  such  cases.  Robson, 
Kehr,  and  others  think  that  many  cases  of  so-called  "catarrhal  jaun- 
dice" are  due  to  pancreatitis  of  mild  degree.  Steadily  increasing,  pain- 
less jaundice,  in  time  becoming  almost  black,  with  distention  of  the 
gall-bladder,  is  very  characteristic  of  carcinoma  of  the  head  of  the 
pancreas,  or  of  the  papilla  of  Vater. 


GENERAL   DIAGNOSTIC   CONSIDERATIONS  63 1 

Fat  necrosis,  first  studied  by  Balser  in  1882,  may  be  seen  when 
the  abdomen  has  been  opened;  it  is  due,  probably  with  very  few  excep- 
tions, to  pancreatic  disease.^  By  fat  necrosis  is  meant  the  result  of  the 
action  of  the  steapsin  of  the  pancreatic  juice  upon  surrounding  fat 
areas,  resulting  in  the  splitting  of  this  fat  into  acids  and  glycerin. 
"Fatty  acids,"  says  Opie,  "are  deposited  as  needle-hke  crystals  within 
the  cell,  which  has  lost  its  nucleus  and  is  evidently  necrotic,  while  the 
soluble  glycerin  is  absorbed.  Very  soon  the  fatty  acids  unite  with 
calcium,  to  form  calcium  salts;  and  within  the  cell  outline  which  is  still 
preserved  are  irregular,  often  globular  masses,  in  which  the  presence  of 
lime  salts  may  be  demonstrated  by  micro-chemical  reactions."  Ac- 
cording to  Ebner  (1907)  fat  necrosis  may  occur  (i)  directly  by  trauma, 
permitting  the  access  of  pancreatic  secretion  to  the  tissues  immediately 
surrounding;  (2)  through  the  lymphatics,  as  noted  by  Bryant,  Bohm,  and 
Gulecke;  (3)  through  the  blood,  for  although  Tschepurowski  found  that 
the  action  of  steapsin  is  inhibited  in  the  circulating  blood,  yet  Payr 
and  Martina  (1907)  have  found  emboli  composed  of  pancreatic  cells. 
Fat  necrosis  which  is  found  widely  disseminated  in  the  abdomen 
(omentum,  mesentery)  is  more  apt  to  be  due  to  diffusion  of  steap- 
sin through  lymphatic  spaces  than  to  direct  transperitoneal  contact 
of  the  pancreatic  juice;  and  certainly  in  the  rarer  instances  of  fat 
necrosis  of  the  subperitoneal,  subcutaneous,  and  pericardial  fat,  any 
direct  transperitoneal  access  of  the  pancreatic  secretion  is  out  of  the 
question.  Bunge  explained  the  occasional  absence  of  fat  necrosis  in 
suppurative  pancreatitis  by  rapid  thrombosis  of  the  lymph-stream. 

The  areas  of  fat  necrosis  vary  in  size  from  less  than  one  to  more 
than  five  milHmetres,  usually  being  visible  as  minute  whitish  specks  or 
flakes,  of  dense  rigid  feel,  often  surrounded  by  a  hemorrhagic  zone,  and 
not  raised  from  the  surface  of  the  surrounding  fat,  a  fact  which  aids  in 
distinguishing  them  from  miliary  tubercles.  It  is  not  unhkely  that 
very  minute  areas  of  fat  necrosis  often  are  overlooked.  The  whitish 
specks  may  be  made  more  conspicuous,  as  Bender  has  shown,  by  the 
application  of  a  half-saturated  solution  of  copper  acetate,  which  turns 
the  affected  area  green,  showing  a  fine  contrast  from  the  yellow  of  the 
normal  surrounding  fat. 

Fat  necrosis  occurs  in  the  acute  lesions  of  the  pancreas  (infections 
and  traumatisms)  with  much  greater  frequency  than  in  chronic  affec- 
tions (interstitial  pancreatitis,  carcinoma),  but  it  appears  to  have  been 
definitely  established  that  it  is  no't  itself  caused  by  bacteria;  these  are  a 

'  Richter  (1910)  noted  its  presence  in  a  case  of  perforated  duodenal  ulcer  and  Marton 
(igig)  in  one  of  gastric  perforation. 


632  SURGERY  OF  THE  PANCREAS 

mere  coincidence.  In  one  case  recorded  by  Hansemann  (i88q),  areas 
of  fat  necrosis  in  the  subcutaneous  tissue  were  found  to  correspond  with 
circumscribed  hemorrhagic  areas  visible  through  the  skin. 

Hemorrhage. — Another  characteristic  of  disease  of  the  pancreas 
is  a  hemorrhagic  tendency.  On  opening  the  abdomen  in  acute  cases 
there  may  be  found  a  bloody  exudate  bathing  the  entire  abdomen; 
various  discrete  hematomata.  sometimes  widely  distinct  from  the 
pancreas,  may  be  encountered;  and  frequently  the  pancreas  itself  is  the 
site  of  a  massive  hematoma,  or  diffuse  petechial  hemorrhages.  It  was 
pointed  out  by  Korte,  as  long  ago  as  1894,  that  these  hematomata  were 
not  scattered  around  by  chance,  but  that  their  situation  might  be  ex- 
plained on  anatomical  grounds,  owing  to  the  disposition  of  the  various 
"peritoneal  leaves"  or  "fascias  d'  accolement"  around  the  pancreas. 
Leriche  and  Arnaud  (1909)  claim  that  the  sanguinolent  effusion  in  the 
general  peritoneal  cavit}-  is  due  to  rupture  of  the  gastro-colic  omentum 
(either  by  trauma  or  by  the  digestive  action  of  the  pancreatic  ferments), 
or  leakage  of  pancreatic  juice  through  the  foramen  of  Winslow,  or  the 
escape  somewhere  of  the  bloody  exudate  arising  originally  in  the  pan- 
creas. Turner  (1920)  has  reported  two  cases  of  acute  pancreatitis  in 
which  ecchymotic  areas  appeared  in  one  case  around  the  umbilicus, 
and  in  the  other  in  the  flank,  from  the  direct  action  of  the  infiltrating 
pancretic  secretions. 

After  operation  on  patients  w-ith  pancreatic  disease,  especially 
infections  and  carcinoma,  there  is  not  seldom  manifested  a  tend- 
ency to  hemorrhage,  not  confined  to  the  wound  alone;  oozing  may 
occur  from  previously  intact  mucous  membranes,  and  subcutaneous 
bleeding,  causing  disfiguring  ecchymoses,  may  result  from  trifling 
causes.  Truhart  and  Doberauer,  according  to  Carnot  (1908),  accused 
the  digestive  action  of  the  pancreatic  trypsin  on  the  neighboring  tissues, 
opening  venules  and  arterioles,  as  the  cause  of  this  hemorrhagic  tend- 
ency; while  poverty  of  the  blood  in  hme  salts,  which  are  excreted  in 
excess  in  cases  of  pancreatic  disease,  was  thought  by  Robson  and  Cam- 
midge  to  be  a  sufficient  explanation. 

Edema  of  the  lower  extremities,  from  pressure  on  the  inferior  vena 
cava,  is  a  rare  sign  of  pancreatic  disease,  as  is  ascites  from  pressure  on 
the  portal  vein.     The  senior  author  has  met  with  ascites  in  one  case. 

Palpation. — In  emaciated  patients,  and  especially  in  those  with 
gastroptosis,  the  diseased  pancreas  often  can  be  detected  by  palpation 
as  an  oblong  tumor,  lying  transversely  above  the  umbihcus,  of  firm 
consistency,  and  usually  more  cord-like  than  might  be  expected. 
Carcinoma  of  the  head  of  the  pancreas  could  be  more  often  detected  by 


GENERAL   DIAGNOSTIC   CONSIDERATIONS  633 

palpation,  were  it  not  obscured  by  a  distended  gall-bladder,  one  of  the 
most  characteristic  physical  signs  of  this  lesion.  In  cases  of  subacute 
and  suppurative  pancreatitis  it  is  almost  always  possible  to  detect  a 
deeply-seated  diffuse  resistance  in  the  epigastrium,  which  on  opening 
the  abdomen  is  found  to  have  been  caused  by  the  pancreas,  engorged 
with  bloody  and  inflammatory  exudate,  or  with  pus.  In  cases  of  acute 
pancreatitis  rigidity  of  the  belly  wall  may  prevent  satisfactory  palpa- 
tion. Cysts  of  the  pancreas  almost  always  can  be  felt  on  palpation, 
but  their  differential  diagnosis  is  more  easily  made  by  percussion,  as  will 
be  presently  described.  Hydronephrosis,  which  in  a  few  cases  has 
resulted  from  pressure  by  the  pancreas  on  the  ureter,  usually  can  be 
recognized  by  palpation  (cases  of  Chvostek  and  of  Boldt,  quoted  by 
Martina,  1907).  On  the  other  hand,  in  a  case  reported  by  Villard  and 
Thevenet  (1909),  a  calculous  hydronephrosis  simulated  a  tumor  of  the 
pancreas  because  it  produced  obstructive  jaundice.  Extravasa- 
tions in  cases  of  acute  pancreatitis  sometimes  are  more  easily  discovered 
by  palpation  in  the  left  loin  than  in  the  epigastric  region. 

Percussion. — This  is  of  most  value  in  determining  the  relation  of 
the  stomach  and  colon  to  supposed  cysts  or  tumors  of  the  pancreas. 
By  distention  of  these  viscera  with  air,  by  means  of  a  hand-bulb 
attached  to  stomach  or  rectal  tube,  it  usually  is  possible  to  ascertain: 
(i)  that  a  given  tumor  is  retroperitoneal  in  origin;  (2)  that  it  presents 
(a)  through  the  gastro-hepatic  omentum,  (b)  through  the  gastro-colic 
omentum,  or  (c)  below  the  transverse  colon.  By  percussion,  also, 
the  size  of  the  liver  may  be  determined;  when  this  is  much  enlarged, 
and  is  accompanied  by  a  distended  gall-bladder  and  deep  jaundice,  the 
diagnosis  of  carcinoma  of  the  pancreas  is  very  probable  (Fig.  166). 

Diagnosis. — In  attempting  to  make  a  diagnosis  in  a  case  of  sus- 
pected pancreatic  lesion,  the  surgeon  should  consider:  (i)  The  pre- 
disposing causes;  (2)  the  clinical  history;  (3)  symptoms;  (4)  physical 
examination;  and  (5)  the  results  of  the  laboratory  tests  of  duodenal 
contents,  urine,  feces,  etc. 

I.  Predisposing  Causes. — Under  this  heading  usually  are  con- 
sidered sex,  age,  race,  etc. 

Sex. — The  male  sex  undoubtedly  is  more  predisposed  to  pancreatic 
disease  than  the  female;  large  statistics  show  that  65  per  cent,  of  cases 
of  pancreatic  disease  occur  in  men. 

Age. — Most  patients  with  disease  of  the  pancreas  are  of  middle  or 
later  life;  in  young  men  or  women  it  is  said  to  occur  chiefly  in  hard 
drinkers,  prematurely  aged. 

Race. — We    are   not    aware    that   marked    prevalence    of   pancre- 


634  SURGERY  OF  THE  PANCREAS 

atic  disease  in  any  race  has  been  observed;  but  in  our  own  experi- 
ence members  of  the  Hebrew  race  seem  to  have  been  in  the  majority, 
as  is  also  the  case  in  disease  of  the  biliary  tract  (page  479). 

Habits. — It  has  long  been  taught  that  hard  drinkers  and  high 
livers  are  exceptionally  predisposed  to  pancreatic  lesions.  This 
has  not  been  our  own  experience;  we  have  found,  however,  that  many 
of  our  patients  with  pancreatitis  (acute  or  chronic)  had  arteriosclerosis 
from  one  cause  or  another. 

Obesity  is  another  factor  which  is  looked  upon  by  some  as  a  pre- 
disposing factor  of  consequence. 

Certain  other  diseases,  of  which  arteriosclerosis  has  already  been 
mentioned,  undoubtedly  greatly  predispose  to  the  development  of 
pancreatic  lesions.  By  far  the  most  important  of  these  is  biliary 
infection:  Quenu  and  Duval  in  1905  computed  that  gall-stones  were 
present  in  50  per  cent,  of  cases  of  pancreatitis;  Egdahl  (1901)  said  about 
42  per  cent,  of  cases  of  pancreatitis  are  associated  with  gall-stones; 
Kehr  (1909)  found  evidence  of  chronic  pancreatitis  in  sixty-nine 
(30  per  cent.)  of  his  last  220  operations  for  biliary  disease;  ^layo  (19 18) 
has  found  go  per  cent,  of  his  cases  of  pancreatic  disease  caused  by  or 
coincident  with  cholelithiasis  or  other  infection  of  the  biliary  tract. 
As  Kehr  points  out,  the  higher  percentage  of  cases  of  pancreatic  disease 
reported  in  recent  statistics  is  to  be  explained  by  more  careful  examina- 
tion of  the  pancreas  at  operation,  such  investigation  being  indicated 
whenever  the  upper  abdomen  is  explored.  Of  seventy-nine  patients 
with  chronic  pancreatitis  under  the  senior  author's  care  in  theLankenau 
Hospital,  seventy-two  (91  per  cent.)  showed  evidence  of  infection  of 
the  bile-passages;  forty-two  (53  per  cent.)  had  gall-stones,  and  in 
thirty  (38  per  cent.)  there  was  non-calculous  inflammation.  Statistics 
may  also  be  given  of  the  percentage  of  cases  of  gall-stone  disease 
in  which  lesions  of  the  pancreas  are  noted;  thus  Mayo  found  that  only 
359  patients  (8.9  per  cent.)  in  a  series  of  4000  cases  of  biliary  disease 
had  also  noticeable  lesions  of  the  pancreas;  Kehr  found  that  in  24 
per  cent,  of  his  patients  with  disease  of  the  biliary  tract  palpable 
lesions  of  the  pancreas  were  present.  Perhaps  it  is  just  as  well  in  this 
place  to  note  that  a  positive  diagnosis  of  chronic  pancreatitis  cannot 
always  be  made  merely  from  palpation  of  the  organ  during  an  operation. 
Many  a  time  such  a  diagnosis  has  been  made,  and  when  opportunity  has 
offered  later  to  test  the  diagnosis  by  the  use  of  the  microscope  no  lesions 
have  been  found.  These  probably  are  cases  of  pancreatic  lymphan- 
geitis.  The  influence  of  general  infections  in  producing  lesions  of  the 
pancreas  has  already  been  noted  (page  614).     Finally  injury  should  be 


GENERAL   DIAGNOSTIC   CONSIDERATIONS  635 

remembered    as    a   predisposing    cause    of    considerable    importance 
(page  689). 

2.  History. — A  good  clinical  history  of  the  patient  is  of  the  utmost 
importance.  The  previous  existence  of  general  infections,  especially 
of  typhoid  fever,  owing  to  its  predilection  for  the  biliary  tract,  the 
occurrence  of  jaundice,  dyspepsia,  colic,  or  "stomach  cramps," — any 
one  of  these  factors,  should  bring  to  mind  the  possibility  of  pancreatic 
infection  as  a  sequel. 

3.  Symptoms. — No  matter  how  trivial  at  first  glance,  all  symp- 
toms should  be  cautiously  weighed,  as  possibly  having  some  bear- 
ing on  the  diagnosis  of  pancreatic  disease.  Thus  dyspnea,  which 
many  will  think  can  have  no  special  diagnostic  value,  is  dwelt  upon 
by  both  Riedel  (1903)  and  Musser  (1908),  as  especially  characteristic 
of  pancreatic  disease;  the  former  states  that  when  during  an  attack 
of  supposed  biliary  colic  dyspnea  is  a  marked  symptom  the  surgeon 
always  should  think  of  pancreatitis  as  a  complication;  Musser  also 
notes  it  as  a  symptom  characteristic  of  acute  pancreatitis.  Dysp- 
nea is  thought  to  be  produced  either  by  reflex  nervous  action  through 
pressure  on  the  solar  plexus,  or  by  means  of  toxic  matters  in  the  circula- 
tion. Collapse,  which  often  is  profound  in  cases  of  acute  pancreatitis, 
is  attributed  to  similar  causes.  Cyanosis  is  a  not  unusual  accompani- 
ment of  collapse  and  dyspnea.  Pain,  in  acute  cases,  is  excruciating; 
in  chronic  pancreatitis  and  in  cancer  of  the  pancreas  it  usually  is  not 
very  severe,  unless  perigastric  adhesions  exist,  or  unless  neighboring 
nerve  trunks  are  compressed.  Pain  is  often  referred  to  the  left  shoulder 
blade,  or  to  the  middle  of  the  back  between  the  shoulders.  Epigastric 
pain  may  be  increased  after  taking  food,  possibly,  as  suggested  by 
Martina,  because  the  physiological  activity  of  the  pancreas  some  hours 
after  a  meal  causes  the  gland  to  swell  up  and  distend  its  peritoneal 
capsule.  A  very  severe  pain  may  be  caused  by  small,  localized, 
intrapancreatic  hemorrhages.  The  pulse  rate  may  remain  normal,  in 
spite  of  the  hemorrhagic  nature  of  the  pancreatic  lesion,  provided  there 
is  no  escape  of  secretions  of  the  pancreas  from  the  confines  of  its  capsule. 
Fever  usually  exists  in  cases  of  infection  of  the  pancreas  which  have 
lasted  for  several  days,  though  in  cases  of  pancreatic  apoplexy  and 
other  hyperacute  lesions  where  collapse  occurs  the  temperature  may 
be  subnormal. 

4.  Physical  Examination. — This  should  be  systematic  and 
complete.  Inspection  shows  the  presence  or  absence  of  emacia- 
ation,  jaundice,  tumor,  dyspnea,  cyanosis,  etc.  Palpation  may  detect 
rigidity  of  the  abdominal  walls;  tenderness  to  pressure  in  the  epigas- 


636  SURGERY  OF  THE  PANCREAS 

trium;  a  deeply  placed  sense  of  resistance  or  a  well-defined  tumor; 
fulness  in  the  left  flank;  a  distended  gall-bladder,  etc.  Percussion 
enables  the  surgeon  to  determine  the  relation  of  the  stomach  and 
colon  to  any  suspected  pancreatic  swelling;  and  to  outline  the  liver 
and  gall-bladder. 

5.  Laboratory  Tests. — Many  of  these  have  already  been  men- 
tioned. The  most  important  are  those  for  detection  of  the  pancreatic 
ferments  in  the  duodenal  contents.  For  examination  of  the  feces: 
I.  Excess  of  fat,  and  diminution  in  the  proportion  of  split  fat  con- 
tained in  the.  feces.  2.  Presence  of  undigested  proteid  material, 
as  determined  by  Schmidt's  test  (page  627).  3.  Absence  of  proteoly- 
tic ferment  as  shown  by  the  test  of  Fedeli  and  Romanelli  (page  628). 
In  the  examination  of  urine,  the  most  valuable  test  is:  Alimentary 
glycosuria  (Wille  's  test,  page  630) .  The  pancreatic  reaction  in  the  urine, 
described  by  Cammidge  (1904),  is  no  longer  considered  of  special  value. 
For  detailed  descriptions  of  these  various  tests  the  reader  is  referred  to 
the  original  communications  of  the  authors,  and  especially  to  the 
writings  of  R.  Gaultier  (1905)  and  of  Terrier  (1906). 

Acute  Pancreatitis 

Under  this  category  are  included  both  catarrhal  and  parenchy- 
matous inflammations.  The  acute  catarrhal  inflammations  of  the 
pancreas  are  neither  so  frequent  nor  so  important  in  surgery  as  the 
parenchymatous  inflammations.  They  are  attended  by  moderate 
swelling  of  the  head  of  the  gland,  which  may  compress  the  common 
duct  and  thus  give  rise  to  "catarrhal  jaundice,"  which,  as  previously 
mentioned  (page  630),  often  may  be  due  to  such  a  condition  as  this 
rather  than  to  edema  of  the  mucous  membrane  of  the  bile-duct  or 
occlusion  of  its  duodenal  orifice.  Suppurative  catarrh  of  the  pancre- 
atic ducts  has  also  been  observed.  But  much  more  importance 
attaches  to  pancreatic  lymphangeitis  and  to  chronic  catarrhal  pancre- 
atitis, which,  as  will  be  shown  subsequently,  are  frequent  forerunners 
of  chronic  interstitial  pancreatitis;  the  pathogenesis,  symptoms,  and 
treatment  of  these  conditions  are  discussed  in  connection  with  the 
latter  subject  (page  667). 

The  parenchymatous  forms  of  acute  pancreatitis  were  classified 
by  Fitz  (1889)  as  hemorrhagic,  suppurative,  and  gangrenous.  The 
differences  are  those  of  degree,  rather  than  of  kind;  and  while  gangren- 
ous pancreatitis  nearly  invariably,  and  suppurative  pancreatitis 
frequently,   is  a  sequel  of   the  primary  hemorrhagic  change,   either 


ACUTE   PANCREATITIS  637 

form  may  arise  independently,  though  the  gangrenous  rarely  does  so. 
The  fullest  account  will  be  accorded  the  primary,  hemorrhagic  form. 

Hemorrhagic  Pancreatitis 

The  tendency  to  hemorrhage  in  disease  of  the  pancreas  has  already 
been  discussed;  but  it  must  not  be  thought  that  the  use  of  the  term 
hemorrhagic  pancreatitis  implies  any  form  of  inflammation  peculiar 
to  the  pancreas  alone.  It  is  well  known  that  in  other  structures  a 
hemorrhagic  form  of  inflammation  is  not  seldom  observed;  and  the 
more  that  is  learned  of  pathological  processes  in  general  and  of  the 
special  pathology  of  the  pancreas  in  particular,  the  more  evident  does 
it  become  that  the  pancreas  conforms  to  general  pathological  laws. 

Pathogenesis. — Hemorrhagic  pancreatitis  has  been  produced  ex- 
perimentally (Carnot,  1908)  by  trauma,  by  injecting  chemicals  into 
the  duct  of  Wirsung  or  directly  into  the  parenchyma  of  the  gland, 
and  perhaps  most  interesting  of  all  by  injections  of  bile,  gastric  juice, 
and  even  normal  pancreatic  juice,  trypsin,  etc.  In  connection  with 
this  auto-digestive  action  of  the  pancreatic  secretion,  the  important 
point  to  observe,  as  explained  at  page  36,  is  that  the  pancreatic  juice 
is  activated  by  a  kinase  with  which  it  comes  in  contact  only  after 
leaving  the  pancreas.  Now,  it  has  been  pointed  out  by  Carnot  that, 
under  abnormal  conditions,  a  kinase  generated  by  leukocytes  or  even 
by  bacteria,  within  the  pancreas,  can  activate  trypsinogen  and  convert 
it  into  trypsin,  and  that  if  this  is  produced  within  the  pancreas  it 
will  have  the  power  of  digesting  the  surrounding  proteid  material. 
By  a  similar  pathological  law,  the  pepsin  of  the  gastric  juice  is  activated 
only  by  hydrochloric  acid;  and  as  it  is  held  by  some  that  auto-digestion 
of  the  stomach,  in  certain  cases,  may  produce  "round  ulcer"' in  that 
organ,  so  from  analogy  it  was  suggested  (Truhart,  1906)  that  trypsin 
may  be  the  direct  cause  of  intrapancreatic  hemorrhages,  producing 
veritable  "round  ulcers"  of  the  pancreas  (Desjardins,  1905);  and 
Mayo  (1918)  speaks  of  these  fulminating  forms  of  pancreatitis  as 
"perforations"  of  the  pancreas.  The  pancreas,  as  is  well  known, 
is  extremely  susceptible  to  post-mortem  auto-digestion;  indeed  it  has 
been  claimed  by  Chiari  (1906)  that  this  process  begins  in  approximatelj' 
50  per  cent,  of  cadavers  within  a  few  hours  of  death,  or  even  during 
the  agonal  period;  and  he  has  expressed  the  opinion  "that  idiopathic 
hemorrhagic  or  gangrenous  pancreatitis  for  the  most  part  is  nothing 
other  than  an  intravital  tryptic  auto-digestion  of  the  pancreas" 
(Williams  and  Busch,  1907).  We  believe  a  very  reasonable  theory 
to  account  for  the  pathogenesis  of  acute  pancreatitis  is  that  so  ably 


638  SURGERY    OF    THE    PAN'CREAS 

supported  by  Archibald  (1919),  namely  retrojection  of  bile  as  a  con- 
sequence of  spasm  of  the  sphincter  of  Oddi  (see  p.  619). 

On  the  other  hand,  the  toxic  agent  producing  the  hemorrhage 
has  been  thought  to  circulate  in  the  blood  or  lymph  streams,  as  in  the 
toxemic  theory  of  the  origin  of  gastric  ulcer  (page  67),  in  typhoid 
fever,  and  in  various  other  infections.  The  hemorrhagic  lesions  in  the 
pancreas  would  then  be  produced  by  ulcerations  commencing  in  the 
endothelial  lining  of  the  vascular  channels.  These  theories  of  patho- 
genesis have  not  been  verified  as  yet  by  pathological  examinations; 
indeed  the  hemorrhages  and  inflammatory  changes  are  often  so  wide- 
spread that  little  pancreatic  tissue  remains  for  histological  study. 

It  is  important  to  observe  that  fat  necrosis  and  hemorrhage  in 
cases  of  pancreatitis  go  hand  in  hand;  the  latter  is  said  by  Dieulafoy 
never  to  exist  without  the  former,  though  fat  necrosis  has  been 
observed  in  numerous  cases  without  any  evidence  of  pancreatic  hemor- 
rhage. We  have  observed  cases,  however,  in  which  intrapancreatic 
hemorrhage  existed,  without  evidences  of  fat  necrosis  elsewhere  than 
in  the  gland  itself.  And  as  the  area  of  fat  necrosis  may  be  widely 
disseminated,  and  not  limited  merely  to  the  surface  of  the  omentum, 
mesentery,  etc.,  but  situated  deep  within  their  substance;  so,  too, 
the  hemorrhages  of  pancreatitis  may  be  confined  neither  to  the  pan- 
creas itself  nor  to  a  sanguineous  peritoneal  effusion,  but  often  exist 
as  distinct  and  separate  hematomata,  in  the  root  of  the  mesentery, 
in  the  omentum,  in  the  peripancreatic  or  perirenal  fat,  etc.,  etc. 
In  other  words  both  fat  necrosis  and  hemorrhage  may  occur  wherever 
the  destructive  pancreatic  secretion  is  carried,  whether  its  path  is, 
intraperitoneal,  along  the  retroperitoneal  tissues,  through  lymph- 
spaces,  or  through  the  blood  stream;  but  this  is  theory,  our  knowledge 
at  present  not  permitting  of  differentiation.  Dieulafoy  attempted 
to  draw  a  sharp  distinction  between  cases  of  hemorrhagic  pancreatitis 
and  cases  of  panceatico-peritoneal  hemorrhage,  the  former  being 
infectious  in  origin  and  the  latter  merely  toxic,  caused  by  the  extra- 
vasation of  pancreatic  juice  which  produces  both  hemorrhages  and 
fat  necrosis  in  various  parts  of  the  abdominal  cavity;  it  arises  not 
infrequentlj'  in  the  course  of  a  chronic  pancreatitis.  It  may  thus  be 
understood  that  a  "pancreatic  apoplexy"  so  called  was  believed  .  to 
arise  without  preceding  infection  or  inflammation ;  probably  such  cases 
are  not  uncommon  at  the  present  day,  and  closer  study  of  very  early 
cases  may  more  and  more  often  show  it  to  be  true  that  infection  follows 
the  chemical  destruction  of  the  gland  but  does  not  precede  or  produce 
it   (p.  620). 


ACUTE    PANCREATITIS  639 

Clinical  Etiology.  Sex. — The  disease  is  more  frequent  in  men  than 
in  women;  large  statistics  show  that  about  65  per  cent,  of  cases  occur 
in  men. 

Age. — Most  patients  are  of  middle  or  later  life,  though  cases  are 
not  unknown  in  young  adults.  In  young  persons  it  is  said  usually  to 
occur  in  hard  drinkers,  who  have  developed  arteriosclerosis  before  the 
usual  time  of  life.  Brewitt  (1908)  and  Korte  (191 1)  have  each  of  them 
operated  successfully  on  a  patient  of  sixteen  years  with  acute  hemor- 
rhagic pancreatitis. 

Obesity  usually  is  considered  an  important  predisposing  cause: 
among  eighty-three  cases  of  acute  pancreatitis,  collected  by  Williams 
and  Busch  (1907),  obesity  was  distinctly  noted  in  fifty,  and  in  many 
others  the  amount  of  adipose  tissue  was  not  mentioned  at  all. 

Previous  digestive  disturbances  have  almost  always  existed;  they 
may  consist  merely  of  gastro-duodenitis  or  of  more  serious  affections. 
Archibald  suggests  the  long  abstinences  from  food  which  characterize 
chronic  alcohoUcs  and  other  patients  with  disturbances  of  the  upper 
digestive  tract  as  a  factor  tending  to  keep  the  sphincter  of  Oddi  closed, 
thus  predisposing  to  the  retrojection  of  bile  into  the  pancreas  (p.  619). 

Cholelithiasis,  however,  is  not  so  frequent  an  accompaniment 
of  acute  as  it  is  of  chronic  pancreatitis.  Kehr  (1901)  observed  acute 
pancreatitis  in  only  i  per  cent,  of  his  operations  for  gall-stone  disease. 
The  statistics  collected  by  Quenu  and  Duval  (1905)  showed  that,  of 
cases  of  pancreatitis  associated  with  gall-stone  disease,  60  per  cent, 
were  cases  of  chronic  pancreatitis,  and  40  per  cent,  of  acute  pancreatitis 
(23  per  cent,  were  cases  of  gangrenous  or  suppurative  pancreatitis, 
and  only  17  per  cent,  were  cases  of  hemorrhagic  pancreatitis).  These 
figures  agree  very  closely  with  those  reported  by  other  observers: 
Notzel  (1908)  reported  nine  cases  of  acute  pancreatitis,  three  of  which 
were  associated  with  gall-stones;  of  the  eighty- three  cases  of  acute 
pancreatitis  collected  by  WilUams  and  Busch  (1907)  thirty-three 
(40  per  cent.)  were  associated  with  gall-stones;  and  Egdahl  (1907) 
found  that  gall-stones  were  present  in  forty-four  out  of  105  cases  of 
acute  pancreatitis.  Opie  (1908)  collected  forty-three  cases  in  which 
gall-stones  and  acute  pancreatitis  were  associated,  in  nine  of  which  a 
calculus  had  lodged  near  the  termination  of  the  bile-duct  and  may  have 
permitted  retrojection  of  bile  into  the  duct  of  Wirsung  (page  618). 
It  was  suggested  by  Williams  and  Busch  that  the  passage  of  a  gall- 
stone into  the  duodenum  may  so  dilate  the  intestinal  orifice  of  the 
common  bile-duct  as  to  facihtate  regurgitation  of  duodenal  contents 
into    the   pancreatic    duct.     Numerous    reports   indicate    that    acute 


640  SURGERY  OF  THE  PANCREAS 

pancreatitis  occurs  by  no  means  infrequently  in  a  gland  already  the 
seat  of  chronic  inflammation. 

Typhoid  Fever. — Musser  (1908)  observed  acute  hemorrhagic  pan- 
creatitis as  a  fatal  complication  of  typhoid  fever. 

Trauma. — It  is  generally  acknowledged  that  trauma  may  be  a 
cause  of  hemorrhagic  pancreatitis,  the  hemorrhage  causing  a  place 
of  lessened  resistance  and  predisposing  the  gland  to  infection;  more- 
over, the  structure  of  the  pancreas  is  such  that  very  insignificant 
trauma  may  result  in  serious  intraperitoneal  hemorrhages. 

Morbid  Anatomy. — On  opening  the  abdomen  early  in  the  course  of  a 
case  of  acute  pancreatitis  there  may  be  found  no  exudate,  and  nothing 
to  indicate  disease  of  the  pancreas,  not  even  scattered  areas  of  fat 
necrosis,  until  the  pancreas  itself  is  brought  to  view  when  it  will  be 
found  pinkish  in  color,  tense  beneath  its  capsule,  and  almost  ready  to 
perforate.  At  a  later  stage,  however,  perhaps  after  the  lapse  of  only  a 
few  hours,  though  sometimes  not  for  several  days,  there  usually  is  found 
a  sero-purulent  exudate,  sometimes  blood-stained  or  even  grumous  in 
character.  In  nearly  all  cases  areas  of  fat  necrosis  are  found  in  the 
omentum,  mesentary  or  peri-pancreatic  fat.  This  exudate  should  not 
be  interpreted  as  a  direct  extension  from  the  diseased  pancreas  in  all 
cases;  it  is  the  evidence  that  the  general  peritoneal  cavity,  and  especi- 
ally the  omentum,  is  reacting  to  the  pancreatic  infection  just  as  it 
does  to  infections  arising  in  the  gall-bladder,  the  appendix,  the  Fall- 
opian tubes,  etc.  In  cases  where  the  exudate  is  blood-stained,  however, 
and  especially  where  there  is  extensive  fat  necrosis,  it  is  probable, 
as  previously  noted  (page  631).  that  the  proteolytic  and  .steatoly tic- 
ferments  of  the  pancreas  have  escaped  from  their  normal  habitat,  by 
way  of  the  lymphatic  spaces  or  possibly  transperitoneally.  The  lesser 
even  before  the  greater  peritoneal  cavity  may  be  invaded  by  the  exudate 
which  early  in  the  course  of  pancreatitis  is  sero-purulent;  later  it  becomes 
bloody,  grumous,  even  chocolate  colored;  rarely  it  is  frankly  purulent. 
Hematomata  may  be  observed  in  the  root  of  the  mesentery,  around  the 
pancreas,  and  in  the  peri-renal  fat.  The  pancreas  itself,  as  already 
mentioned,  in  the  very  early  stages  of  the  disease,  may  present  no 
very  noteworthy  macroscopic  changes  except  that  it  may  be  enlarged; 
but  very  soon  it  becomes  intiltrated  with  blood,  which  is  conspicuous 
because  in  isolated  spots  separated  by  yellowish  white  areas  of  normal 
pancreatic  tissue.  In  the  course  of  a  few  days,  if  death  docs  not  occur 
sooner,  the  pancreas  may  be  converted  into  a  reddish-black  mass  of 
necrotic  fat  and  blood  clots  (Plate  IX).  The  disorganization  of  the 
gland  usuallv  is  so  extensive  that  little  of  value  can  be  learned  from  a 


Plate  IX 


ACUTE    PANCREATITIS  64I 

microscopical  study.     The  hemorrhages  are  interstitial,  rarely  invading 
the  ducts. 

If  the  patient  lives,  the  lesions  of  gangrenous  pancreatitis  may  be 
observed  after  the  lapse  of  ten  days  or  two  weeks.  In  this  stage  a 
large  portion  of  the  pancreas,  usually  the  body  or  tail,  may  be  found 
almost  completely  detached  from  the  surrounding  tissues,  lying  as  a 
slough  in  the  retroperitoneal  fat.  The  evidences  of  general  peritoneal 
infection  are  now  very  slight,  but  the  entire  lesser  peritoneal  cavity  may 
be  converted  into  an  abscess  containing  foul-smelling,  purulent,  choco- 
late-colored exudate,  with  pieces  of  necrotic  pancreas  floating  around 
loose  in  the  fluid.  In  rare  instances  the  stomach,  jejunum  or  transverse 
colon  may  be  perforated.  In  a  case  recorded  by  Chiari  most  of  the 
pancreas  (identified  by  Rokitansky)  was  passed  from  the  rectum  as  a 
slough;  this  was  also  the  case  in  a  patient  of  Trafeyer.  In  a  patient 
under  the  care  of  the  senior  author  nearly  the  entire  pancreas  was  dis- 
charged as  a  slough  through  a  lumbar  incision  made  for  drainage 
(Plate  IX).  This  case  has  been  reported  in  full  by  Jurist  (1909).  The 
patient  continued  in  good  health  for  about  six  years,  but  eventually 
died  with  diabetes. 

Lesions  of  the  biliary  tract,  a  common  accompaniment  of  acute 
pancreatitis,  may  also  be  observed  on  inspection  of  the  abdomen  at 
operation  or  post-mortem.  They  require  no  particular  description  in 
this  place,  but  it  is  perhaps  well  to  note  that  fat  necrosis  has  been 
observed  in  a  few  cases  apparently  as  the  result  of  leakage  of  the 
pancreatic  juice  through  a  perforation  or  rupture  of  the  biliary  appa- 
ratus, stomach  or  duodenum  (Richter,  1910;  Marton,  1919),  the  pan- 
creas itself  not  being  diseased. 

Symptoms. — There  is  little  doubt  that  as  experience  accumulates, 
it  will  be  possible  to  recognize  milder  attacks  of  acute  pancreatitis  than 
the  fulminating  cases  which  hitherto  almost  exclusively  have  occupied 
the  attention  of  surgeons.  Prodromal  symptoms,  in  the  nature  of 
digestive  disturbances,  stomach  or  gall-stone  cramps,  etc.,  are  said  to 
exist  in  70  per  cent,  of  cases;  but  often  the  acute  symptoms  arise  so 
suddenly,  and  are  of  such  an  overwhelming  nature,  that  the  patient  can 
give  no  detailed  history  of  his  previous  condition,  and  such  prodromal 
symptoms  are  discovered  only  by  inquiries  from  the  patient  after 
recovery  from  operation,  or  from  his  friends  after  his  death.  The 
disease  usually  runs  its  course  in  from  five  to  eight  days,  death  occurring 
within  a  week  in  the  great  majority  of  cases  without  operation.  In  a 
few  cases,  however,  if  no  operation  is  done,  the  symptoms  abate,  and 
when  about  the  tenth  day  the  hemorrhagic  or  purulent  eft'usion  has 


642  SURGERY  OF  THE  PANCREAS 

become  localized,  physical  examination  may  enable  a  diagnosis  of 
suppurative  pancreatitis  to  be  made  (page  654). 

The  attack  is  characterized  by  both  abdominal  and  constitutional 
symptoms.  Of  the  first,  pain  and  vomiting  are  the  most  important,  and 
of  the  latter,  collapse. 

Pai«.— This  occurs  suddenly  in  the  epigastric  region,  and  may 
be  so  severe  as  to  cause  faintness  or  collapse.  It  is  a  colicky  pain  at 
first,  probably  from  sudden  overdistention  of  the  gland  as  the  result  of 
intrapancreatic  hemorrhage.  Sudden  death  may  arise  by  inhibition  of 
the  heart.  A  rapid,  but  not  sudden,  death  is  more  apt  to  be  caused 
by  toxemia.  The  pain  resembles  in  its  coHcky  nature  that  due  to 
intestinal  obstruction,  but  often  it  is  extremely  severe  at  its  lirst  onset, 
whereas  the  pain  of  obstruction  frequently  begins  with  mere  twinges 
and  becomes  severe  only  after  the  lapse  of  hours.  The  pain  of  pan- 
creatitis does  not  shift  its  position,  but  remains  constantly  epigastric, 
usually  more  to  the  left  than  the  right  of  the  median  line.  Pain  may 
also  be  felt  in  the  dorsal  region,  usually  to  the  left  of  the  spine,  or  in  the 
left  shoulder  blade.  It  seems  not  unlikely  in  those  cases  attended  by 
extremely  severe  pain,  which  cannot  be  relieved  by  morphin  and  which 
impels  the  patient  to  rise  from  the  bed  and  walk  around  the  room  and 
frequently  change  his  position,  and  which  are  not  attended  by  marked 
collapse — that  in  these  cases  the  hemorrhagic  exudate  is  still  confined 
by  the  capsule  of  the  pancreas,  not  having  broken  through  into  the 
general  peritoneal  cavity;  and  that  it  is  the  latter  event  which  brings 
on  collapse.  We  have  observed  a  few  such  cases  where  this  gtate  of 
affairs  was  demonstrated  at  very  early  operation.  In  such  patients 
the  pulse  may  remain  full  and  strong  and  of  normal  rate.  This  may 
serve  to  differentiate  the  condition  from  intestinal  obstruction  in  which 
the  pulse  rate  usually  rises  rapidly  even  before  the  onset  of  peritonitis 
and  fever. 

Vomiting  is  an  early  and  important  sjTnptom.  It  follows  closely 
after  the  initial  pain  and  is  repeated  so  frequently  as  to  resemble  that 
due  to  intestinal  obstruction;  but  in  the  latter  condition  the  vomiting  is 
projectile,  there  is  little  or  no  nausea  and  retching,  and  the  vomitus 
soon  becomes  bile-stained  and  then  fecal.  In  acute  pancreatitis,  on  the 
other  hand,  the  vomitus  is  never  fecal,  and  frequently  (when  the  bile- 
duct  is  obstructed)  it  is  not  even  bile-stained;  there  usually  is  con- 
siderable nausea  and  retching,  the  gastric  and  duodenal  contents  being 
brought  up  only  with  difficulty.  Hiccough  is  a  frequent  symptom,  is 
often  repeated,  and  very  persistent. 

Jaundice   is    of   rather  frequent  occurrence  in  acute  pancreatitis 


ACUTE   PANCREATITIS  643 

either  from  primary  calculous  obstruction,  or  secondarily  from  com- 
pression of  the  bile-duct  by  the  diseased  pancreas. 

Emaciation. — This,  which  is  extremely  rapid,  is  very  character- 
istic of  pancreatitis  in  all  its  forms. 

Collapse. — This  is  not  seen,  as  a  rule,  until  perforation  into  the  gen- 
eral peritoneal  cavity  occurs.  Then  the  extremities  are  cold,  the  face 
and  hands  are  covered  with  cold  sweat,  the  nose  looks  pinched;  there 
is  mental  hebetude;  sometimes  great  restlessness  and  thirst;  delirium  is 
rare,  except  in  later  stages.  The  symptoms  of  collapse  probably 
are  due  to  the  absorption  of  toxins  of  the  broken-down  pancreatic 
tissue  (Egdahl,  1907);  mechanical  irritation  of  the  peritoneum  and 
stimulation  of  the  celiac  plexus  are  also  secondary  causes. 

Pulse. — In  the  presence  of  collapse  this  is  rapid,  feeble,  and  often 
indicates  the  hemorrhagic  nature  of  the  abdominal  disease;  but  as 
already  noted,  so  long  as  the  toxic  extravasation  is  confined  within 
the  capsule  of  the  pancreas,  the  excruciating  pain  has  dominated  the 
picture  and  collapse  has  been  absent,  and  the  pulse  has  been  slower 
than  normal  and  quite  strong  (Elliot,  1910). 

Temperature. — This  may  be  subnormal  and  is  seldom  high,  early 
in  the  disease.  When  the  collapse  passes  off,  and  under  the  influence 
of  the  peritonitis,  it  may  be  high,  and  in  cases  of  abscess  of  the  pancreas 
may  assume  a  hectic  type. 

Dyspnea. — This,  which  perhaps  is  more  accurately  described  as 
hypernea,  has  been  noted  by  several  keen  observers  as  a  symptom 
characteristic  of  acute  pancreatitis.  It  is  probably  due  in  part  to 
mechanical  interference  by  the  engorged  pancreas  with  the  action 
of  the  diaphragm;  in  part  to  the  severe  pain,  and  in  part  to  the  toxemia 
as  in  the  parallel  case  of  uremic  dyspnea. 

Convulsions,  followed  by  coma  and  death,  were  the  chief  symp- 
toms noted  in  a  case  reported  by  Tomaschny:  as  the  patient  (an 
old  woman  with  senile  dementia)  had  never  had  epilepsy  and  as 
the  kidneys  were  normal  and  there  was  no  diabetes,  Tomaschny 
concluded  that  the  convulsions  were  either  reflex,  from  pressure  on 
the  solar  plexus,  or  toxemic  in  origin;  on  the  under  surface  of  the 
dura  mater  there  were  some  small  yellow  spots  perhaps  areas  of  fat 
necrosis;  this  was  also  present  in  the  peripancreatic  fat. 

Physical  Signs. — Thorough  physical  examination  usually  is 
impossible  at  the  first  onset  of  the  disease,  owing  to  the  extreme  degree 
of  abdominal  pain  and  tenderness.  Inspection  shows  a  slightly  dis- 
tended epigastrium,  with  thoracic  breathing;  cyanosis  is  frequent 
and  livid  splotches  on  the  surface  of  the  abdomen  have  been  noted 


644  SURGERY  OF  THE  PANCREAS 

several  times  (p.  632).  On  palpation,  the  muscular  rigidity  is  not 
found  to  be  very  marked;  in  a  few  cases  gentle  but  persistent  examin- 
ation of  the  epigastrium  with  the  warm  flat  hand  has  enabled  the 
surgeon  to  detect  that  the  swelling  was  diffuse,  and  not  simply  depen- 
dent on  a  distended  stomach  or  colon.  Gentle  palpation  in  the  left 
costo-iliac  space  may  discover  an  abnormal  fullness,  as  well  as  exquisite 
tenderness,  from  the  pancreatic  extravasation  in  the  retro-peritoneal 
tissues.  Percussion  may  demonstrate  an  area  of  dullness  in  the 
region  of  the  pancreas,  between  the  ensiform  process  and  the  umbilicus. 
Clinical  Cotirse. — After  the  extremely  sudden  onset  of  an  attack 
of  acute  pancreatitis,  characterized  by  violent  epigastric  pain,  repeated 
vomiting,  and  collapse;  the  symptoms  of  peritonitis  supervene,  and 
are  the  dominant  feature  of  the  case  during  the  second  and  third 
days  of  the  disease.  After  this  time,  unless  death  occurs,  the  symp- 
toms generally  grow  less  severe,  and  the  physical  signs  of  subacute 
pancreatitis  (gangrenous  or  suppurative  stage)  arise.  The  patient 
continues  to  be  gravely  ill.  though  suffering  less  intensely  than  at 
first;  the  stomach  is  unretentive,  though  vomiting  usually  is  absent 
if  entire  abstinence' from  mouth  feeding  is  persisted  in,  as  it  should 
be;  emaciation  is  rapid;  slight  jaundice  frequently  is  present;  the 
pulse  is  weak  and  running;  the  temperature  elevated  (100°  to  io2°F.) 
and  sometimes  assumes  a  hectic  type.  In  the  epigastrium  an  indistinc- 
tly outlined  and  deep-lying  tumor  usually  can  be  detected  by  palpation, 
and  the  rest  of  the  abdomen  may  be  no  longer  painful.  The  patient 
will  now  die  of  exhaustion,  sepsis  or  secondary  peritonitis  from  rupture 
of  the  pancreatic  abscess,  unless  promptly  relieved  by  operation. 
Differential  Diagnosis. — Unless  a  surgeon  has  seen  previously 
two  or  three  cases  of  acute  pancreatitis,  or  unless  he  keeps  the  con- 
dition constantly  in  mind,  it  is  seldom  that  a  correct  diagnosis  is 
made  before  opening  the  abdomen;  and  it  is  generally  admitted  that 
any  attempt  to  distinguish  between  the  various  forms  of  acute  pancre- 
atitis (hemorrhagic,  suppurative,  gangrenous),  in  the  present  state 
of  our  knowledge,  is  utterly  futile. 

The  conditions  for  which  acute  pancreatitis  is  most  often  mistaken 
are  biliary  colic;  acute  intestinal  obstruction;  perforation  of  the 
stomach,  duodenum  or  gall-bladder;  and  appendicitis. 

Biliary  colic  presents  many  of  the  symptoms  of  acute  pancreatitis, 
and  a  distinction  may  be  very  difficult.  In  acute  pancreatitis,  how- 
ever, there  usually  is  not  a  history  of  recurrent  attacks;  it  is  more 
apt  to  follow  overeating  than  is  biliary  colic;  and  the  pain  though 
subject  to  exacerbations,  as  in  biliarj'  cohc,  scarcely  ever  is  entirely 


ACUTE    PANCREATITIS  645 

absent  between  these  exacerbations;  the  pain,  moreover,  is  very 
much  more  intense  in  the  pancreatic  affection — indeed  it  is  seldom 
relieved  by  the  morphin  which  may  be  given  in  large  and  repeated 
doses  under  the  impression  that  the  condition  really  is  biliary  colic. 
In  pancreatitis  there  is  collapse,  cyanosis,  and  a  sense  of  impending 
death,  which  seldom  are  noted  in  cases  of  biliary  colic. 

Intestinal  Obstruction. — The  difference  in  the  character  of  the 
onset  and  in  the  nature  of  the  pain  have  been  mentioned  already 
(page  642) :  in  addition,  there  frequently  is  a  history,  in  cases  of  acute 
intestinal  obstruction,  of  a  previous  attack  of  peritonitis  which  might 
have  left  behind  crippling  adhesions,  etc.  The  collapse  is  not  so 
great  as  in  pancreatitis,  the  temperature  is  not  elevated,  and  the 
onset  of  peritonitis,  with  fever,  wiry  pulse,  and  distended  abdomen  is 
more  delayed.  The  vomiting  is  projectile,  with  little  or  no  nausea 
or  retching,  and  rapidly  becomes  fecal  in  the  case  of  obstruction; 
whereas  in  pancreatitis  the  nausea  is  marked,  the  gastric  and  duodenal 
contents  are  brought  up  only  with  effort,  and  though  the  vomiting 
may  be  often  repeated  (every  ten  to  fifteen  minutes),  fecal  vomiting 
scarcely  ever  is  observed.  A 'slight  icteric  tinge  of  the  sclera  is  present 
sometimes  in  pancreatitis,  but  is  very  rare  in  intestinal  obstruction; 
persistent  absence  of  bile  from  the  vomitus  speaks  in  favor  of  pancre- 
atitis. In  both  affections  there  nearly  always  is  absolute  constipation, 
and  in  both  an  evacuation  of  the  lower  bowel  sometimes  may  be 
secured  by  the  use  of  enemata  even  after  the  abdominal  symptoms 
are  well  advanced.  In  most  cases  of  pancreatitis,  however,  the 
peritoneal  overshadow  the  intestinal  symptoms,  while  the  reverse 
is  the  case  in  the  early  hours  of  obstruction.  Active  peristalsis  will 
be  heard  in  obstruction,  but  will  be  absent  in  pancreatitis.  Physical 
examination  is  more  apt  to  be  negative  in  cases  of  pancreatitis  than 
in  cases  of  intestinal  obstruction,  since  here  the  existence  of  a  tumor 
(intussusception,  volvulus)  sometimes  may  be  demonstrated. 
Dyspnea  and  cyanosis,  if  present,  point  to  pancreatic  disease.  In 
addition  to  all  the  above  differential  points,  it  must  be  remembered 
that  intestinal  obstruction  is  more  common  in  the  young  (intussuscep- 
tion, Meckel's  diverticulum,  appendicitis)  and  in  the  old  (carcinoma, 
strangulated  hernia,  volvulus),  while  pancreatitis  is  most  frequent 
in  males  of  later  middle  life. 

Perforation  of  the  Stomach,  Duodenum  or  Gall-bladder. — In  these 
conditions  it  is  possible  in  the  vast  majority  of  cases  to  obtain  a  history 
of  gastric  or  biliary  symptoms  extending  over  a  number  of  years. 
In  cases  of  perforation  of  the  gall-bladder  the  patient  almost  invariably 


646  SURGERY  OF  THE  PANXREAS 

will  have  been  confined  to  his  bed  for  some  days  at  least  with  upper 
abdominal  symptoms,  and  frequently  the  distended  gall-bladder  can 
be  recognized  before  perforation  occurs.  The  onset  of  the  attack 
in  cases  of  perforation  of  a  hollow  viscus,  though  often  quite  as  sudden 
as  in  acute  pancreatitis,  and  though  attended  by  very  severe  pain, 
is  yet  unattended  by  the  marked  collapse  which  is  characteristic  of 
the  latter  condition,  and  the  vomiting  seldom  is  repeated.  As  opera- 
tion is  demanded  even  at  an  earlier  period  in  cases  of  perforation  than 
in  acute  pancreatitis  the  differential  diagnosis  is  of  more  academic 
than  practical  importance.     (See  also  page  91.) 

Appendicitis. — While  the  initial  pain  in  appendicitis  is  umbilical 
and  colick}'.  as  is  often  the  case  in  acute  pancreatitis;  yet  it  is  not  so 
severe,  collapse  is  rare,  and  vomiting  is  not  repeated.  The  pain  of 
appendicitis  localizes  itself  in  a  few  hours  to  the  right  iliac  region,  and 
any  mass  which  forms  will  be  here  or  in  the  pelvis;  while  a  palpable 
mass  forming  as  the  acute  symptoms  of  pancreatitis  subside  will  be  in 
the  epigastric  region,  slightly  to  the  left  of  the  median  line,  or  in  the  left 
loin.  The  age  of  the  patients  is  different,  and  a  history  of  previous 
attacks  of  appendicitis  may  throw  further  light  on  the  diagnosis. 

Gynecological  afeciions,  such  as  ovarian  tumors  with  twisted  pedicle, 
rupture  of  a  tubal  pregnancy,  etc.,  usually  may  be  excluded  by  atten- 
tion to  the  history  and  a  careful  pelvic  examination. 

Poisoning. — ^Leriche  and  Arnaud  (iQog)  suggest  that  the  cases  of 
hj-peracute  pancreatitis  ("pancreatic  apoplexy"),  followed  by  death 
in  a  few  hours  in  a  state  of  collapse,  might  be  mistaken  for  poisoning  by 
drugs  and  they  recommend  that  pancreatitis  be  remembered  as  a  cause 
of  sudden  death  in  cases  having  a  medico-legal  aspect. 

Prognosis. — Acute  pancreatitis  is  now  regarded  as  a  surgical  dis- 
ease; this  is  conceded  by  most  physicians,  and  there  are  good  reasons 
why  it  should  be  so.  Under  purely  medical  treatment  the  vast  ma- 
jority of  patients  with  acute  pancreatitis  died.  In  1908  Dreesmann 
collected  case  records  from  the  past  ten  years,  which  showed  that  of 
thirty-six  cases  of  acute  pancreatitis  treated  without  operation,  only 
four  recovered;  a  mortality  of  88  per  cent.;  while  of  118  cases  subjected 
to  operation  fifty-three  recovered,  a  mortality  of  only  55  per  cent. 
The  statistics  collected  by  Ebner  (1907)  may  be  added:  of  twenty 
patients  treated  without  operation,  eighteen  died,  a  mortality  of  90  per 
cent.;  of  thirty-six  patients  subjected  to  operation,  nineteen  died,  a 
mortality  of  47.2  per  cent.;  and  while,  as  Dreesmann  suggests,  such 
statistics  as  these  no  doubt  give  an  unduly  favorable  record  for  the 
operative  cases,  since  successful  are  more  apt  to  be  reported  than 


ACUTE   PANCREATITIS  647 

unsuccessful  operations,  yet  the  difference  between  the  medical  and 
surgical  results  is  so  extreme  that  little  further  argument  is  needed. 

With  this  limitation  in  mind,  it  is  interesting  to  see  the  gradual 
improvement  in  operative  results  which  is  evidenced  in  the  following 
statistics. 

In  1906  Lenormant  and  Lecene  found  six  recoveries  among  thirty- 
six  operations  (mortality  83.3  per  cent.). 

In  1909,  Leriche  and  Arnaud  found  (since  1906)  thirteen  recoveries 
among  thirty-nine  operations  (mortality  66.6  per  cent.). 

In  191 1,  Korte  found  among  118  isolated  operations  reported 
since  1905,  seventy-three  recoveries  and  forty-five  deaths  (mor- 
tality 38  per  cent.). 

In  191 7  Linder  reported  a  series  of  operations,  collected  within  the 
previous  three  years.  Up  to  1915,  there  were  16  operations  with  a 
mortality  of  62.5  per  cent.  In  the  second  series,  since  191 5,  comprising 
15  operations,  the  correct  diagnosis  was  made  in  75  per  cent,  of  the 
cases,  and  the  mortality  was  only  13.6  per  cent. 

Bloodgood  (1919)  reports  a  series  of  11  operations,  with  3  deaths 
(27.2  per  cent.). 

It  has  been  argued  that  patients  who  are  finally  subjected  to  opera- 
tion sometimes  give  a  history  of  having  passed  through  similar  attacks 
before,  recovering  without  operation;  but  it  is  even  more  difficult  to 
diagnose  an  attack  of  acute  pancreatitis  from  vague  descriptions 
given  by  the  patient  of  a  previous  illness  than  it  is  when  we  see  him 
during  the  attack;  and  it  seems  not  impossible  that  some  of  these  acute 
attacks  from  which  the  patients  are  alleged  to  have  recovered  have  been 
attacks  of  biliary  disease.  Yet  it  is  true  that  some  of  the  operations 
followed  by  recovery  (Halsted,  Dick)  consisted  in  little  more  than 
opening  the  belly  and  sewing  it  up  again;  but  one  or  two  cases  are  not 
enough  to  controvert  the  dictum  that  without  operation  the  prognosis 
is  shockingly  bad. 

The  first  recovery  after  operation  with  drainage  is  credited  to 
Hahn  (1900). 

As  to  the  time  at  which  operation  shall  be  undertaken,  surgeons 
are  gradually  becoming  unanimous  in  their  view  that  immediate 
intervention  offers  most  chances  of  success.  All  those  whose  experience 
has  been  greatest  in  the  treatment  of  acute  pancreatitis,  urge  immediate 
operation;  and  even  Korte,  who  at  first  (1S98)  advised  waiting  until  the 
subacute  stage  on  the  ground  that  no  operation  could  be  of  benefit  in 
patients  so  acutely  ill,  revised  his  teaching  in  1907,  and  then  asserted 
his  opinion  that  operation  as  soon  as  possible  after  the  onset  of  symp- 


648  SURGERY  OF  THE  PANCREAS 

toms  affords  the  best  chance  of  cure.  And  as  we  learn  more  of  the 
pathology  of  the  affection,  this  seems  the  only  reasonable  ground  to 
take:  the  conditions  in  acute  pancreatitis  are  in  many  respects  similar 
to  those  present  in  traumatic  lesions  of  this  region — escape  of  pan- 
creatic juice  into  the  peri-pancreatic  tissues  and  the  general  peri- 
toneal cavity,  and  hemorrhage.  If  the  case  were  traumatic  in  origin, 
no  one  would  counsel  delay  in  opening  the  abdomen  and  attempting 
to  evacuate  the  toxic  fluid  (absorption  of  which  causes  the  collapse, 
etc.)  and  to  check  the  bleeding  by  tampon  or  suture.  As  a  matter 
of  fact,  however,  very  few  operations  have  been  done  within  a  few 
hours  of  the  onset  of  the  attack;  usually  the  patient  does  not  come 
under  surgical  care  until  the  second  or  third  day  of  the  disease,'  and 
we  believe  that  under  such  circumstances,  as  in  other  cases  of  diffuse 
peritonitis,  it  is  safer  sometimes  to  encourage  localization  of  the  process 
before  instituting  drainage.  But  it  should  be  distinctly  understood 
that  by  urging  postponement  of  operation  at  this  stage  we  do  not 
mean  to  leave  the  patient  alone  until  he  is  nearly  moribund  from  sepsis: 
sometimes  it  may  be  possible  to  wait  until  a  well-localized  tumefaction 
indicates  the  presence  of  an  abscess  or  of  gangrene;  but  whenever  a  case 
is  seen  before  symptoms  of  diffuse  peritonitis  arise,  the  surgeon  should 
lose  no  time  in  opening  the  abdomen  to  evacuate  the  e.xtravasated 
toxic  fluid.  In  general,  we  believe  that  immediate  operation  should  be 
done,  unless  such  a  course  manifestly  would  hasten  death;  under  such 
circumstances,  and  when  the  patient  is  first  seen  when  diffuse  peri- 
tonitis is  well  advanced,  it  will  be  safer  to  postpone  operation,  relying 
on  the  "Ochsner  treatment"  to  encourage  localization  of  the  process.    . 

.Acute  Pancre.witis.     Oper.wion  in  the  Subsiding  St,a.ge;   Recovery 

\  Polish  woman,  24  years  of  age  was  admitted  to  the  German  Hospital  Nov.  5,  igi6. 
She  had  been  perfectly  well  until  two  days  before  admission,  when  she  was  seized  with  the 
most  acute  abdominal  pain,  followed  by  vomiting. 

On  admission  the  abdomen  was  greatly  distended,  rigid  and  universally  tender;  the 
tenderness  was  more  marked  s  cm.  above  the  umbilicus  and  to  the  right  of  the  midline. 
A  tentative  diagnosis  of  acute  appendicitis  with  peritonitis  was  made,  and  the  patient  was 
treated  by  anatomical  and  physiological  test,  being  placed  setting  up  in  bed  with  ice  to 
the  abdomen,  and  nothing  by  mouth.  .\t  the  end  of  three  days  peristalsis  was  audible 
but  no  flatus  had  been  passed.  The  abdomen  was  becoming  relaxed  below  but  was  still 
rigid  above  the  umbilicus.  Two  days  later  there  was  an  area  of  dulness  demonstrable  in 
the  upper  left  quadrant  of  the  abdomen.     Cystoscopy  and  catheterization  of  the  ureters 

'Thus  in  Hahn's  case  (1900),  already  alluded  to.  operation  was  not  undertaken  until 
three  days  after  the  onset  of  the  disease;  Bunge's  patient  (1903)  quoted  far  and  wide  as  an 
incontrovertible  proof  of  the  value  of  immediate  operation,  was  not  operated  on  until 
sixty  hours  after  the  onset  of  the  attack. 


ACUTE    PANCREATITIS 


649 


were  negative.  X-ray  examination  showed  merely  a  diffuse  shadow  in  the  upper  left 
quadrant. 

The  diagnosis  was  now  revised  to  pancreatitis  with  effusion. 

Operation  (5  days  after  admission,  one  week  after  onset  of  illness),  by  Dr.  Deaver, 
demonstrated  widespread  fat-necrosis.  The  stomach  was  pushed  upward  and  there  was 
bulging  of  the  thickened  gastro-colic  omentum,  where  a  fluctuating  area  was  found.  In- 
cision evacuated  a  large  amount  of  pus  and  bloody  fluid  from  the  lesser  peritoneal  cavity. 
Drainage  was  provided  by  two  wide  rubber  tubes,  coffer-dammed  by  three  gauze  packs 
each  30  cm.  by  100  cm.  in  size. 

Uneventful  recovery;  3J2  years  later  she  was  reported  to  be  in  good  health. 

It  is  almost  impossible  to  secure  figures  which  will  give  any  clear 
indication  of  the  truth  in  this  matter,  for  the  case  reports  as  a  rule 
do  not  give  the  number  of  hours  elapsed  between  onset  of  the  attack 
and  operation,  nor  do  they  clearly  define  the  stage  of  disease  (hemor- 
rhagic or  suppurative)  in  which  operation  is  undertaken;  and  even 
if  such  figures  were  compiled,  from  scattered  case  reports,  they  could 
not  convey  the  real  truth,  because  successful  operations  are  always 
reported  sooner  than  unsuccessful.  Nor  would  the  patients  who 
had  died  without  operation  be  included  in  such  statistics.  Korte 
(191 2)  attempted  to  show  the  results  obtained  by  those  who  have 
reported  more  than  one  operation  (presumably  their  entire  experience  in 
each  instance);  he  collected  in  this  manner  reports  of  103  operations: 
among  these,  forty-one  patients  recovered,  and  sixty-two  died,  a 
mortality  of  56.9  per  cent.  Korte 's  own  experience  (embracing  ten 
cases  of  his  colleague  Brentano)  includes  forty-four  cases  of  acute 
pancreatitis,  in  the  period  from  1890  to  1910.  Only  cases  where  the 
diagnosis  was  proved  at  operation  or  at  autopsy  are  counted.  In 
six  cases  no  operation  was  done,  and  all  the  patients  died.  In  thirty- 
eight  cases  operation  was  done:  in  four  cases  the  gall-bladder  was 
drained  and  nothing  was  done  to  the  pancreas;  all  the  patients  died. 
In  thirty-four  cases  the  usual  operation  on  the  pancreas  was  done, 
with  eighteen  recoveries  and  sixteen  deaths  (47  per  cent,  mortality). 

Koete's  Operations 


Acute  Pancreatitis 

Total 

Recovered 

Died 

Mortality 
per  cent. 

In  the  first  week  of  the  disease 

12 
4 
7 
7 

4 

34 

8 
3 
4 
3 
0 

18 

4 

I 
3 
4 
4 

16 

33-3 
25.0 

43  0 

S7-0 

100. 0 

In  the  second  week  of  the  disease 

In  the  third  week  of  the  disease 

In  the  fourth  week  of  the  disease 

From  the  fifth  to  the  seventh  week 

47.0 

650 


SURGERY    OF    THE   PANCREAS 


There  are  few,  if  any,  surgeons  who  have  had  so  extensive  an 
experience  with  this  disease  as  has  Korte.  In  the  table  pubUshed 
in  the  first  edition  of  this  work,  we  assembled  the  statistics  of  those 
surgeons  whose  experience  most  nearly  approached  his.  This  comprised 
a  total  of  193  cases  with  119  deaths,  a  mortality  of  61  per  cent.;  ;^2  of 
these  patients  were  treated  without  operation,  with  8  recoveries  and  24 
deaths,  a  mortality  of  75  per  cent.;  while  161  patients  were  subjected 
to  operation,  with  67  recoveries  and  94  deaths,  a  mortality  of  58.3 
per  cent. 

As  is  the  case  in  every  other  department  of  surgery,  the  mortality 
of  operative  treatment  begins  to  decrease  as  the  disease  in  question 
becomes  better  recognized,  and  particularly  as  the  individual  surgeon's 
experience  increases  and  as  his  judgment  and  his  technical  skill  im- 
proves. So  that  at  the  present  day  the  death  rate  is  considerably 
less  than  indicated  by  the  figures  just  quoted. 

In  the  first  edition  of  this  work  the  senior  author  recorded  11 
operations  for  acute  pancreatitis,  with  5  deaths  a  mortality  of  45  per 
cent.  Since  191 2  he  has  operated  on  24  patients,  with  only  9  deaths 
(37.5  percent.). 

Operations  for  Acute  Pancreatitis  (1012-1020) 
(Lankenau  Hospital) 


Operation 


Associated  lesions 


Cases 


Deaths 


Cholecystostom}' 

Cholecystostomyand  pancreatos 
tomy 

Cholecystectomy  and  choledo 
chostomy 

Cholecystectomy    and    pancrea 

tostomy 

Pancreatostomy 


No  other  lesion 

Calculus 

Pancreatic  abscess,  calcu- 
lus  

Cirrhosis  liver 

No  other  lesion 

No  other  lesion 

Calculus 

Pancreatic  abscess 

Pancreatic  abscess,  calcu- 
lus   

Calculus 

No  other  lesion 


24       9  =  375%  mortality 


Treatment. — When   operation   is   undertaken,   a   certain   definite 
technique  should  be  followed.     In  cases  where  the  diagnosis  is  un- 


ACUTE   PANCREATITIS 


651 


certain,  the  surgeon  may  make  his  first  incision  in  the  hypogastric 
region;  but  if  he  is  an  acute  clinician  it  usually  will  be  possible  for 
him  to  determine  before  beginning  whether  the  seat  of  disease  is  in 
the  lower  or  upper  abdomen.  In  any  case,  however,  pancreatic 
disease  is  to  be  suspected  so  soon  as  the  abdomen  is  opened  if  there  is 
a  bloody  turbid  exudate,  or  if  there  is  fat  necrosis;  marked  distention 
of  the  transverse  colon,  without  apparent  obstruction,  is  another 
valuable  sign.  If  only  an  exploratory  hj'pogastric  incision  has  been 
made  (as  is  best  in  cases  of  uncertain  diagnosis),  it  should  be  tempora- 
rily plugged  with  gauze;  an  incision  is  then  made  in  the  epigastrium, 
through  the  left  or  right  rectus. 
The  pancreatic  lesion  may  now 
be  self-evident;  and  the  stomach 
may  be  displaced  by  the  swollen 
gland  simply  forward,  or  upward 
or  downward;  rarely  the  colon  will 
be  displaced  upward,  and  the 
pancreas  prove  most  accessible 
through  the  transverse  meso- 
colon. When  a  choice  is  pos- 
sible, the  surgeon  should  aim  to 
expose  the  pancreas  through  the 
gastro-colic  omentum,  dividing 
this  structure  between  the  gastro-epiploic  vessels  and  the  colon,  as 
described  at  page  295  (Fig.  160) ;  but  if  the  pancreas  bulges  through  the 
gastro-hepatic  omentum  or  through  the  transverse  meso-colon,  it 
should  be  approached  by  that  route. 

Having  thus  exposed  the  pancreas  itself,  many  surgeons  have  been 
content  to  conclude  their  intervention  at  this  point  by  tamponing 
the  lesser  peritoneal  cavity,  without  opening  the  capsule  of  the 
pancreas.  Notzel  (1908),  Stieda  (1910),  and  others  who  recom- 
mend this  plan  contend  that  incision  of  the  swollen  hemorrhagic 
pancreas  may  lead  to  uncontrollable  hemorrhage,  and  will  give  exit 
to  exceedingly  toxic  substances  which  will  be  more  rapidly  absorbed 
by  the  peritoneum,  and  thus  more  quickly  destroy  the  patient,  than 
if  they  were  still  confined  to  the  substance  of  the  inflamed  gland. 

Direct  incision  of  the  pancreas  was  first  proposed  in  1893  by  Nimier, 
who  suggested  controlling  the  hemorrhage  by  the  actual  cautery 
or  by  gauze  packing.  It  appears  to  have  been  put  into  execution 
first  by  C.  B.  Porter  in  February,  1903,  closely  followed  (December, 
1903)  by  Muspratt,  both  patients  recovering. 


Fig.  160. — Wide  Opening  of  the  Gastrocolic 
Omentum  to  Explore  the  Pancreas. 


652  StTRGERY    OF    THE    PANCREAS 

As  far  as  our  own  experience  goes,  and  from  what  can  be  gathered 
from  case  reports  of  other  surgeons,  there  is  no  object  in  incising  the 
pancreas  unless  it  appears  distended,  or  unless  there  is  a  hematoma 
present.  In  several  cases  operated  on  in  the  hemorrhagic  stage 
(Bunge.  Hahn.  Coenen,  Xotzel)  the  evidences  of  intra-pancreatic 
damage  have  been  comparatively  slight,  and  recovery  has  followed 
mere  tamponade  of  the  lesser  peritoneal  cavity.  In  Coenen's  patient 
(Case  i)  there  was  no  exudate  at  the  time  of  operation,  but  seven 
days  after  operation  there  occurred  a  profuse  discharge  of  pancreatic 
secretion  from  the  wound,  with  sloughs  of  the  pancreas;  and  in  Notzel's 
patient  (Case  3)  no  cause  for  the  peritonitis  was  found  at  the  time  of 
operation,  so  the  wound  was  tamponed,  but  reopened  during  the  sub- 
acute stage  when  the  pancreatic  exudate  was  evacuated.  The  cases 
recorded  by  Bunge  and  Hahn  are  similar. 

On  the  other  hand  we  do  not  think  such  great  fear  of  systemic 
poisoning  need  be  felt  if  the  distended  pancreatic  capsule  is  incised 
to  give  exit  to  dammed-up  secretions  or  blood  clots;  indeed  it  seems  not 
improbable  that  there  is  less  danger  of  absorption  from  the  serous 
surface  of  the  peritoneum  than  from  the  retroperitoneal  cellular  tissues. 
In  every  case,  of  course,  the  pancreas  should  be  opened  only  after  care- 
fully protecting  the  general  peritoneal  cavity  by  a  cofTer-dam  of  gauze; 
and  if  there  is  any  localized  collection  of  fluid,  this  may  well  be  eva- 
cuated first  by  an  aspirator,  still  further  to  decrease  the  chance  of 
soiling  the  peritoneum,  the  abscess  or  hematoma  being  formally  incised 
only  after  its  contents  have  been  withdrawn. 

Bircher  (1910)  successfully  excised  the  entire  tail  of  the  pancreas 
which  was  the  seat  of  a  hematoma  on  the  third  day  after  onset  of 
symptoms;  and  he  urges  excision  whenever  possible,  as  the  removal  of 
the  focus  of  disease,  as  of  a  gangrenous  appendix,  should  accelerate 
the  cure. 

Another  question  in  dispute  is  whether  or  not  any  treatment 
of  bihary  complications  should  be  undertaken  when  the  abdomen 
is  opened  in  a  case  of  acute  pancreatitis.  This  was  urged  as  a  measure 
of  routine  by  Ebner  (1907),  but  the  proper  course,  it  seems  to  us, 
depends  upon  the  state  of  the  bihary  tract  and  the  condition  of  the 
patient.  Should  the  latter  warrent  such  interference,  we  see  no  good 
reason  for  postponing  drainage  of  the  gall-bladder  if  this  is  easily 
accessible  and  is  the  seat  of  acute  cholecystitis,  or  contains  calcuh;  if 
on  the  other  hand  the  gall-bladder  is  buried  in  adhesions,  if  there  is 
doubt  as  to  its  being  acutely  diseased,  or  if  for  any  reason  the  calculi 
present  are  particularly  inaccessible,  it  no  doubt  would  be  proper  to 


ACUTE   PANCREATITIS  653 

postpone  to  a  more  opportune  time  any  indicated  operative  treatment 
of  the  biliary  tract,  even  if  the  condition  of  the  patient  were  reasonably 
good.  Rarely  we  believe,  will  the  condition  of  the  patient  justify  chole- 
cystectomy or  any  procedure  more  radical  than  drainage  of  the  gall- 
bladder; though  in  the  cases  in  which  we  have  removed  the  gall-bladder 
the  mortality  has  been  lowest  of  all.  When  because  of  the  patient's 
condition  it  is  necessary  to  postpone  surgical  treatment  of  biliary 
lesions,  the  surgeon  should  not  forget  that  a  diseased  biliary  tract  will 
require  treatment  sooner  or  later.  It  is  better  to  do  two  operations 
on  a  Hving  patient,  than  to  do  one  thorough  operation  and  have  a 
dead  patient. 

Archibald  (1919)  suggests  the  propriety  of  incising  the  papilla  of 
Vater  by  duodenotomy,  to  prevent  further  damming  up  of  bile; 
but  we  belive  that  in  most  cases  choledochotomy  with  passage  of  a 
sound  down  the  duct  into  the  duodenum  will  prove  safer. 

Many  surgeons  still  urge  free  irrigation  of  the  peritoneal  cavity 
with  saline  solution;  they  claim  that  not  only  is  it  important  to  secure 
evacuation  of  all  the  exudate,  but  that  owing  to  its  toxic  nature  it  is 
extremely  desirable  to  dilute  it.  As  cultures  from  the  bloody  exudate 
have  in  a  large  number  of  cases  shown  it  to  be  sterile,  and  as  sufficient 
evacuation  is  secured  through  absorption  by  the  gauze  packs  used 
during  the  operation,  it  seems  to  us  quite  unnecessary  to  irrigate  the 
abdominal  cavity;  the  practice  probably  is  not  as  undesirable  as  in 
cases  of  appendicular  peritonitis,  but  that  is  the  most  that  can  be  said 
in  its  favor.  In  all  cases  where  much  effusion  is  found  in  the  general 
peritoneal  cavity,  the  pelvis  should  be  drained  through  a  suprapubic 
incision. 

We  may  sum  up  the  technique  of  operation  for  acute  pancreati- 
tis as  follows:  through  an  epigastric  incision  isolate  the  pancreatic 
region  by  gauze  packs;  if  a  collection  of  fluid  exists,  evacuate  it  by 
aspiration;  expose  the  pancreas  preferably  through  the  gastro-colic 
omentum,  and  if  it  presents  no  gross  lesions  do  not  incise  it,  but  merely 
tampon  the  lesser  peritoneal  cavity;  if  there  is  a  hematoma  or  abscess 
in  the  pancreas,  incise  its  capsule,  and  with  a  blunt  instrument  carry 
the  incision  into  the  substance  of  the  gland,  to  secure  drainage  of  all 
pockets  of  pus,  etc.  Then  tampon  the  incision  into  the  pancreas, 
using  a  large  rubber  tube  for  drainage  in  the  center  of  the  tampons.  In 
some  cases  a  counter-incision  in  the  left  loin  will  be  desirable,  as  in  cases 
of  subacute  pancreatitis  (page  656).  Should  a  hypogastric  incision 
have  been  made  at  first  through  inadvertence,  it  should  be  plugged 
temporarily  with  gauze,  and  may  be  used  at  the  conclusion  of  the  oper. 


654  SURGERY  OF  THE  PANCREAS 

ation  for  pelvic  drainage,  if  this  seems  indicated;  but  in  many  cases  it 
is  better  to  close  it  entirely.  The  biliary  tract  should  be  drained 
except  for  very  positive  contra-indications, 

After-treatment  does  not  differ  materially  from  that  employed 
in  other  acute  lesions  of  the  upper  abdomen.  If  the  patient 
does  well,  it  may  be  expected  that  there  will  be  rather  free  discharge 
from  the  drains,  and  that  after  four  or  five  days  some  evidence  of  pan- 
creatic fluid  will  be  found  on  the  dressings.  Should  meteorism,  vomit- 
ing, fever,  etc.,  reappear  some  days  after  operation,  the  patient  having 
done  well  meantime,  the  surgeon  should  suspect  either  a  fresh  pancreatic 
hemorrhage  or  at  least  that  his  drains  are  blocking  rather  than  aiding 
the  evacuation  of  sloughs  or  pus  from  the  pancreas;  in  such  circum- 
stances a  new  operation  is  indicated,  to  establish  better  drainage,  as 
recommended  by  Lerchie  and  Arnaud  (1909);  but  this  should  not  be 
undertaken  until  lavage  of  the  stomach  and  large  bowel  have  proved 
ineffectual  in  arresting  the  symptoms.  In  some  cases,  on  the  other 
hand,  we  believe  that  too  early  removal  of  the  gauze  tampons  is  respon- 
sible for  the  spread  of  the  pancreatic  secretions  and  the  development  of 
a  fatal  peritonitis.  These  secretions  require  much  denser  adhesions 
than  do  ordinary  purulent  exudates  to  keep  them  from  breaking 
through  the  drainage  tract  into  the  healthy  peritoneum. 

After  the  first  few  days  the  case  will  resemble  one  of  subacute 
pancreatitis,  so  that  a  more  detailed  account  of  the  after-treatment 
may  well  be  postponed  until  that  subject  has  been  considered. 

Subacute  Pancreatitis 
(Abscess  and  Gangrene  of  the  Pancreas) 

Abscess  or  gangrene  of  the  pancreas  usually  arises  as  a  sequel 
of  acute  inflammation  of  the  gland;  very  seldom  is  abscess  a  primary 
condition,  and  almost  never  does  gangrene  occur  except  during  the 
subacute  stage  which  succeeds  to  an  attack  of  "acute  hemorrhagic 
pancreatitis."  Some  writers  attempt  to  distinguish  between  suppura- 
tive pancreatitis  and  abscess  of  the  pancreas.  Robson,  for  instance, 
compares  the  former  to  acute  suppurative  mastitis  and  the  latter  to 
mammary  abscess;  but  though  such  a  distinction  is  quite  proper  theo- 
reticallj-  we  doubt  the  ability  of  surgeons  to  make  a  clinical  distinction 
with  the  means  at  present  at  our  command;  and  it  is,  we  believe,  also 
impossible  to  distinguish  between  the  suppurative  a.nd  gangrenous  forms 
of  the  disease. 


ABSCESS   AND    GANGRENE    OF   THE   PANCREAS  655 

The  diagnosis,  in  fact,  rests  more  upon  the  clinical  course  (page 
644)  of  the  affection,  and  upon  the  physical  signs,  than  upon  the  symp- 
toms which  the  patient  presents.  The  evidences  of  deep-seated 
swelling  in  the  epigastric  region,  following  upon  an  acute  peritoneal 
attack,  always  should  make  the  surgeon  suspicious  of  pancreatic 
trouble;  but  the  physical  signs  often  are  very  Uke  those  of  subphrenic 
abscess  (page  402),  which  condition  indeed  may  be  due  to  pancreatic 
disease.  Among  the  forty-four  cases  of  suppuration  in  the  lesser 
peritoneal  sac  studied  in  1904  by  Michel  and  Gross  twenty-four  were 
certainly,  and  four  probably,  caused  by  pancreatic  disease,  six  by  affec- 
tions of  stomach  and  esophagus,  one  by  perforation  of  the  colon,  seven 
by  splenic  affections;  while  in  two  the  cause  was  undetermined. 

Pancreatic  abscesses  may  reach  a  large  size:  Fasano  (1908)  reported 
one  containing  four  liters  of  pus,  and  Coenen's  (1910)  fifth  patient  had 
one  which  contained  more  than  a  liter  and  a  half.  These  abscesses 
have  a  tendency  to  point  (i)  in  the  lumbar  regions  (Brentano  and 
Rotter  have  reported  cases  pointing  simultaneously  in  both  loins) ; 
(2)  anteriorly  in  the  abdominal  region;  or  (3)  in  the  left  thoracic  region 
(Guinard).  In  the  first  instance  the  signs  of  perinephric  abscess  will  be 
simulated,  and  in  the  third,  those  of  pyopneumothorax  or  subphrenic 
abscess;  while  those  pointing  ateriorly  may  be  mistaken  for  subphrenic 
abscess  due  to  subacute  perforation  of  the  stomach.  In  all  cases  how- 
ever, there  usually  will  be  the  history  of  sudden  hyperacute  onset,  with 
collapse,  peritoneal  symptoms,  etc.,  and  then  as  the  patient  gradually 
recovers  from  the  first  violence  of  the  attack  there  will  be  the  develop- 
ment of  these  secondary  signs  of  upper  abdominal  or  subphrenic  sup- 
puration; and  it  is  on  the  clinical  history  of  the  disease,  plus  these 
physical  signs,  and  not  on  one  or  the  other  alone,  that  a  diagnosis  must 
be  based. 

Treatment  consists  in  evacuation  of  the  abscess  and  drainage 
of  the  pancreas,  with  removal  of  such  sloughs  as  are  already  detached. 
The  abscess  should  be  approached  where  it  is  about  to  point;  but  if  the 
surgeon  wishes  to  save  his  patient's  life  he  must  not  wait  for  subcuta- 
neous fluctuation  to  enable  him  to  determine  this  point.  In  many 
cases  it  will  be  best  to  make  an  exploratory  epigastric  incision,  so  soon 
as  it  is  determined  that  some  form  of  subacute  pancreatitis  is  present, 
and  then  to  make  a  counter-incision  in  the  loin  or  elsewhere,  as  may  be 
shown  by  this  exploration  to  be  best. 

I.  The  Abdominal  Route. — After  opening  the  abdomen  through 
the  left  rectus,  in  the  epigastric  region,  the  intestines  are  walled  off 
with  gauze  packs,  and  the  pancreas  is  palpated;  if  at  all  feasible,  the 


6s6  SURGERY  OF  THE  PANCREAS 

lumbar  route  is  now  emploj-ed  for  drainage.  If  this  does  not  seem 
possible,  access  to  the  pancreas  is  gained  preferably  through  the  gastro- 
colic omentum.  If  a  frank  abscess  is  found,  it  should  be  evacuated  by 
aspiration,  and,  when  emptied,  the  abscess  wall  should  be  incised. 
Sloughs  which  are  entirely  loose  are  then  extracted,  but  those  which  are 
still  attached  even  in  part  should  not  be  detached  roughly  for  fear  of 
exciting  hemorrhage  or  spreading  infection.  The  abscess  cavitj'  is  then 
tamponed,  a  rubber  drainage  tube  being  placed  in  the  midst  of  the 
gauze  packs.  The  gall-bladder  should  then  be  inspected,  and  if  acutely 
inflamed  or  containing  calculi,  should  be  drained,  or  removed,  unless 
distinct  contraindications  exist.  Such  drainage  is  better  done  through 
a  stab  wound  on  the  right.  The  gauze  used  as  coffer-dam  to  protect 
the  general  peritoneal  cavity  during  the  operation,  is  then  removed 
and  the  abdominal  incision  is  closed  not  too  tightly  around  the  gauze 
and  tube  drainage.  It  is  not  necessary  nor  is  it  advisable  to  attempt 
to  suture  the  walls  of  the  abscess  ca\aty  or  the  edges  of  the  opening  in 
the  gastro-colic  omentum  to  the  parietal  peritoneum.  The  abdominal 
route  is  preferred  by  Desjardins  in  all  cases;  but  Brentano.  who  has 
operated  on  six  patients  with  pancreatic  necrosis,  with  only  two  deaths, 
employed  the  abdominal  route  in  only  one  case,  which  terminated 
fatally. 

2.  The  Lumbar  Route. — This  we  believe  to  be  preferable  to  the 
abdominal  route  whenever  it  can  be  employed.  As  mentioned  above 
the  applicabilit}'  of  this  route  sometimes  cannot  be  determined  except 
by,exploratory  laparotomy.  But  if  bulging,  or  even  marked  tenderness 
without  other  signs,  can  be  detected  in  the  left  costovertebral  angle,  an 
incision  as  for  kidney  operations  should  be  made  here  without  pre- 
viously opening  the  abdomen.  Care  is  necessary  not  to  penetrate  the 
peritoneum;  the  dissection  is  carried  beneath  the  lower  pole  of  the  kid- 
ney, and  by  burrowing  with  the  finger  toward  the  middle  line,  little 
difficulty  should  be  experienced  in  locating  the  pancreatic  exudate. 
The  abscess  is  freely  opened,  and  drained  with  tube  and  gauze.  As 
already  mentioned  Brentano  and  Rotter  have  each  opened  (1909)  a 
pancreatic  abscess  through  both  loins  simultaneously.  The  lumbar 
route  has  been  employed  several  times  successfully  by  the  senior  author. 
(See  Plate  IX,  facing  p.  640.) 

3.  The  Thoracic  Route. — This  has  been  particularly  commended 
by  Guinard,  by  whom  it  has  been  employed  twice  with  success.  In 
the  first  case  (1898)  he  operated  two  months  and  a  half  after  the  onset 
of  acute  pancreatitis  on  a  patient  who  had  already  had  a  discharge  of 
pus  through  the  vagina,  with  sudden  subsidence  of  the  pancreatic 


ABSCESS  AND  GANGRENE  OF  THE  PANCREAS  657 

tumor;  when  this  refilled  operation  was  undertaken  and  the  abscess 
was  reached  by  the  usual  transpleural  route  employed  for  subphrenic 
and  hepatic  abscess.  (See  Hepatic  Abscess,  page  552.)  In  his  second 
case  (1907)  operation  was  done  two  weeks  after  the  acute  onset,  for 
signs  resembling  left  pyopneumothorax,  or  subphrenic  abscess.  Korte 
(191 1)  used  the  transpleural  route  in  three  cases,  one  patient  recovering; 
and  Nordmann  (1913)  also  reports  a  successful  case. 

Prognosis. — If  the  condition  is  lecognized  and  operation  is  done 
at  the  appropriate  time,  the  prognosis  is  not  bad.  But  the  surgeon 
must  be  constantly  on  the  alert,  so  as  not  to  let  the  opportune  time 
for  surgical  intervention  slip  past.  As  soon  as  the  acute  process 
shows  signs  of  localization,  but  before  hectic  temperature,  chills, 
sweats,  emaciation,  etc.,  show  that  septic  absorption  is  going  on,  the 
pancreas  should  be  drained  (see  case  report,  p.  648).  Though  cases 
have  been  reported  in  which  spontaneous  discharge  of  pancreatic 
abscesses  has  occurred  (through  the  stomach,  rectum,  vagina,  and 
in  the  lumbar  and  iliac  regions),  and  though  in  one  or  two  of  these 
cases  the  patients  have  recovered  without  operation,  no  such  termina- 
tion should  be  waited  for;  and  though  even  sloughs  of  nearly  the 
entire  pancreas  have  been  discharged  through  the  rectum  (Trafeyer, 
Chiari),  it  is  not  too  much  to  say  that  were  such  an  event  to  occur 
to-day  the  patient  would  recover  more  by  good  luck  than  by  good 
management. 

That  the  mortality  after  operation  in  the  subacute  stage,  as 
reported  by  many  surgeons,  is  lower  than  that  attending  early  opera- 
tion, is  not  an  argument  in  favor  of  delay  in  resorting  to  operation. 
It  indicates  merely  that  the  patients  who  have  suivived  through  the 
earlier  stages  of  the  disease  have  been  less  seriously  ill  from  the  first 
or  have  possessed  better  recuperative  powers.  Robson  (1907)  gave 
the  mortality  for  acute  pancreatitis  as  61  per  cent.,  and  that  for  the 
subacute  stages  as  36  per  cent.  Villar  (1909)  gave  78  per  cent,  as  the 
mortality  for  hemorrhagic  pancreatitis,  38  per  cent,  for  the  suppur- 
ative and  49  per  cent,  for  the  gangrenous  form.  Mettin  (1912)  reported 
a  mortality  of  71  per  cent.,  for  operations  done  during  the  hemorrhagic 
or  suppurative  stages;  and  of  66  per  cent,  for  those  done  during  the 
stage  of  necrosis. 

After-tretament. — This  comprises  both  local  and  general  treatment. 
The  outer  dressings  will  require  frequent  changing  at  first,  but  the 
gauze  drainage  should  not  be  removed  until  it  becomes  loose  of  itself; 
when  this  stage  is  reached,  there  is  no  object,  so  long  as  free  drainage 
exists,  in  keeping  the  wound  widely  open.     Sloughs  may  be  discharged 


65S  SURGERY  OF  THE  PANCREAS 

from  time  to  time,  and  the  surgeon  usually  finds  that  closure  of  the 
wound  is  less  rapid  than  he  had  anticipated,  and  that  his  best  efforts 
will  have  to  be  directed  not  at  keeping  it  open  but  in  encouraging 
it  to  heal.  Protection  of  the  skin  surrounding  the  wound  is  best 
secured  by  covering  it  with  ointment  of  zinc  oxide.  Constitutional 
treatment  is  important,  the  patients  becoming  rapidly  emaciated 
and  requiring  stimulants  and  nutritious  food.  Antidiabetic  diet 
should  be  used,  consisting  almost  entirely  of  fats  and  albumen,  as 
advised  by  Wohlgemuth  (1910),  and  sodium  bicarbonate  should  be 
administered  during  meals  to  lessen  the  gastric  acidity,  which  is  an 
excitant  of  pancreatic  secretion;  or  pankreon  may  be  given  to  sub- 
stitute the  pancreatic  secretion  lost  through  the  fistula.  Erepton 
proved  effective  in  closing  a  pancreatic  fistula  in  a  case  of  rupture 
of  the  pancreas  reported  by  Kroiss  (iqii);  about  100  grams  were 
given  daily,  20  grams  at  a  dose,  by  mouth  in  much  sweetened 
coffee  or  warm  milk;  or  by  rectum  in  doses  of  50  grams.  In  this 
patient,  no  change  occurred  in  the  profuse  discharge  from  the  fistula 
for  a  week  after  the  administration  of  erepton  was  begun;  then  the 
fistula  closed  rapidly  in  three  days  and  remained  healed. 

Chronic  Pancreatitis 

Chronic  pancreatitis  is  an  inflammation  of  the  pancreas  resulting 
from  bacterial  infection  not  severe  enough  to  produce  the  acute  type 
of  inflammation  which  has  already  been  studied.  The  channels  of 
infection  in  cases  of  pancreatitis  have  been  considered  at  length  at 
page  614. 

It  has  been  usual  to  classify  chronic  pancreatitis  as  catarrhal 
or  interstitial,  according  as  the  ducts  or  the  interstitial  tissues  are 
especially  affected. 

Chronic  Catarrhal  Pancreatitis. — In  this  lorm,  which  is  termed 
also  sialodochitis  pancreatica,  the  infection  is  believed  to  reach  the 
ducts  of  the  pancreas  by  way  of  the  duodenum  and  common  bile- 
duct,  for  the  reasons  already  set  forth  (page  617).  This  form  of 
pancreatitis  is  considered  by  Mayo  Robson  and  others  to  be  of  frequent 
occurrence.  The  number  of  cases  available  for  micioscopical  study 
has  been  small,  necessarily,  as  death  seldom  occurs  at  this  stage  of 
the  disease,  and  even  if  it  did  attention  might  not  be  directed  particu- 
larly to  the  pancreas.  Some  cases,  however,  have  been  studied; 
and  while  the  usual  lesions  present  in  catarrhal  inflammation  of  glandu- 
lar   organs    have  been   found    (cloudy  swelling,   desquamation,  etc.) 


PANCREATIC.   LYMPHANGEITIS  659 

there  also  have  been  present  interstitial  changes,  which  in  our  belief, 
as  will  be  stated  presently,  are  of  more  import  than  the  strictly  catar- 
rhal features  of  the  inflammation. 

The  symptoms  of  chronic  catarrhal  pancreatitis,  according  to 
Mayo  Robson,  usually  are  not  to  be  distinguished  fiom  those  .which 
he  describes  as  due  to  chronic  interstitial  pancreatitis;  and  the  treatment 
is  the  same. 

Pancreatic  Lymphangeitis.— Reference  to  this  condition  at  page 
620  has  indicated  our  belief  that  most  cases  classed  together  under  the 
general  term  of  "Chronic  pancreatitis"  are  at  first  really  cases  of  pan- 
creatic lymphangeitis,  the  infection  being  propagated  from  the  gall- 
bladder and  bile-ducts  or  from  the  pyloric  region  of  the  intestine 
along  their  efferent  lymph-channels,  which  come  into  intimate  relation 
with  those  surrounding  and  imbedded  in  the  head  of  the  pancreas 
(Deaver  and  Pfeiffer,  191 2).  Not  only  the  grosser  lesions  of  the  gall- 
bladder and  juxta-pyloric  regions,  such  as  cholecystitis  and  gastric 
or  duodenal  ulcer,  should  be  considered  in  this  connection,  but  also 
those  more  frequent  minor  infectious  processes  which  pathologically  are 
termed  catarrhal  and  which  usually  fail  of  clinical  recognition,  except 
as  "indigestion"  or  "dyspepsia."  We  are  accustomed  now  to  recognize 
extremely  mild  grades  of  inflammation  of  the  gall-bladder  by  the 
presence  of  ever  so  slight  thickening,  diminution  in  lustre,  increased  opac- 
ity, or  inspissation  and  tarry  character  of  its  contents.  If  the  same  at- 
tentive scrutiny  were  directed  to  the  stomach  and  duodenum,  slight 
thickening,  local  puckering  or  distortion  and  increased  opacity  in 
many  cases  otherwise  obscure  might  reveal  the  present  or  past  existence 
of  inflammation.  As  evidence  of  previous  inflammation  we  have 
observed  dimpling  of  the  wall,  at  times  suggestive  of  the  starting 
point  of  an  intussusception.  Filmy  adhesions,  so  well  described  by 
R.  T.  Morris  (1905)  as  "cob-webs  in  the  attic  of  the  abdomen,"  should 
not  pass  unnoticed;  they  are  clear  evidence  of  a  previous  inflammatory 
process.  Less  noticeable,  but  significant  when  observed,  is  a  peculiar 
streaked,  opaque  appearance  aft'ecting  a  very  limited  portion  of  the 
gastro-duodenal  wall  and  often  fading  away  in  adjacent  peritoneal 
attachments.  Of  course  the  grosser  cicatrices  of  healed  ulcers  are 
readily  seen,  but  these  less  conspicous  changes  should  be  looked  for, 
since  they  indicate  in  many  instances  the  previous  existence  of  inter- 
stitial inflammatory  processes.  Catarrhal  inflammation,  fissures,  and 
even  early  ulcers,  may  exist  without  external  evidence  of  their  presence; 
and  yet  they  act  as  portals  of  bacterial  invasion  as  proved  by  the  enlarge- 
ment of  the  regional  lymph-nodes. 


66o  SURGERY  OF  THE  PANCREAS 

The  lymphatics  of  the  pancreas  have  been  studied  thoroughly 
by  Bartels  (1904,  1906,  1907)  and  the  following  description  is  taken 
largely  from  his  work,  and  from  that  of  Franke  (191 1),  who  has  studied 
the  relation  of  the  biliary  lymphatics  to  the  pancreas.  The  pancreas, 
unlike  certain  other  organs,  possesses  no  great  hilum  through  which 
pass  the  afferent  and  efferent  blood-  and  lymph-vessels.  These  ves- 
sels are  distributed  to  the  pancreas  in  a  triore  or  less  segmental  manner. 
Thus  the  blood-vessels  which  supply  the  head  of  the  pancreas  are 
quite  distinct  in  origin  from  those  which  supply  the  rest  of  the  gland; 
and  these  latter,  derived  from  the  splenic  artery,  supply  each  its  own 
more  or  less  isolated  segment,  though  of  course  intra-pancreatic 
anastomoses  exist.  In  a  like  manner  the  pancreatic  lymph-channels, 
arising  in  the  interior  of  the  gland,  come  to  its  surface  by  many  dif- 
ferent and  quite  distinct  trunks.  These  trunks  communicate  with 
various  groups  of  lymph-nodes  around  the  pancreas,  the  most  impor- 
tant of  which  are  thus  enumerated  by  Bartels:  the  classification  is 
made  according  to  the  situation  of  the  lymph-nodes  and  the  portion 
of  the  pancreas  which  they  drain. 

Group  I.  The  Pancreatico-splenic  Group. — These  lymph-nodes 
are  situated  above  and  behind  the  tail  of  the  pancreas  in  the  hilum  of 
the  spleen.  They  lie  along  the  splenic  vessels  between  the  layers  of  the 
gastro-splenic  omentum.  The  lymph-vessels  coming  out  of  the  tail 
of  the  pancreas  run  to  these  nodes. 

Group  II.  The  Superior  Pancreatic  Group. — These  lymph-nodes 
lie  along  the  superior  border  of  the  pancreas  and  receive  the  lymph- 
vessels  coming  from  the  upper  portion  of  the  body  of  the  pancreas. 
There  is  no  sharp  differentiation  between  this  and  the  pancreatico- 
splenic  group  and  their  vessels  anastomose  freely.  Included  in  the 
superior  pancreatic  group  are  the  nodes  lying  behind  the  pylorus, 
often  spoken  of  as  the  retropyloric  nodes.  In  addition  to  these  con- 
nections the  lymph-vessels  from  the  upper  border  of  the  pancreas  have 
connections  with  the  superior  gastric  nodes  (including  the  cardiac) 
and  also  with  the  hepatic  nodes. 

Group  III.  The  Inferior  Group. — This  consists  of  a  small  number 
of  lymph-nodes  situated  along  the  lower  border  of  the  pancreas.  From 
the  lower  portion  of  the  body  of  the  pancreas  lymphatic  vessels  run  to 
these  nodes  and  also  to  the  aortic,  mesenteric  and  mesocolic  groups. 

Group  IV.    The  Pancreatico-duodenal  Group.  Anterior  and  Posterior. 
These  lymph-nodes  lie  around  the  head  of  the  pancreas  and  receive' 
vessels  from  the  pancreas  and  from  the  duodenum. 

In   adch'tion    to   indirect   communication   by   way   of   the   lymph- 


PANCRKATIC    LYMPHANGEITIS  66 1 

atic  nodes  there  is  also  direct  communication  by  anastomosis  between 
the  duodenal  and  pancreatic  lymphatic  vessels.  In  addition  to  this 
direct  communication  there  are  also  anastomoses  between  the  pancreatic 
lymph-vessels  and  those  from  the  duodenum  running  to  the  mesen- 
teric nodes.  Of  especial  interest  from  the  clinical  standpoint  is 
the  communication  shown  to  exist  between  the  vessels  from  the  head  of 
the  pancreas  and  a  lymph-node  situated  between  the  portal  vein  and 
the  common  duct.       Lymphatics  run  from  the  liver  to  this  node. 

It  is  in  this  particular  that  Franke's  work  supplements  that  of 
Bartels.  Franke  showed  by  Gerota  injections  that  the  lymphatic 
vessels  of  the  gall-bladder  run  to  nodes  which  lie  to  the  left  of  the  head 
of  the  pancreas  near  the  common  duct.  On  the  way  the  greater  part 
of  these  vessels  are  in  relation  with  a  node,  which,  when  present,  is 
situated  at  the  neck  of  the  gall-bladder.  By  injection  from  the  gall- 
bladder Franke  filled  a  plexus  of  lymph-vessels  situated  on  the  posterior 
surface  of  the  head  of  the  pancreas. 

These  four  groups  of  lymph-nodes  receive  tributaries  not  only 
from  corresponding  portions  of  the  pancreas  but  also  from  neigh- 
boring viscera,  the  spleen,  stomach,  left  adrenal,  liver  and  duodenum. 
The  efferent  vessels  from  the  pancreatic  nodes  run  to  the  parietal  lymph- 
node  groups  of  the  abdominal  cavity. 

Lymphatic-born  infection  from  these  areas  in  order  to  reach  the 
pancreas  must  in  most  cases  stem  the  elTerent  current  from  the  pan- 
creas and  force  the  valves.  Here,  as  elsewhere  in  the  body,  the  lymph- 
atics are  wonderfully  efficient  in  preventing  this  outcome.  Only  when 
the  intercommunications  of  the  pancreatic  lymphatics  with  those  of 
adjacent  organs  are  most  intimate,  short  in  their  course,  and 
unprotected  by  interveining  lymph-nodes,  does  peril  arise.  Such 
an  extremely  intimate  relationship  Bartels  has  shown  to  exist  between 
the  lymphatics  of  the  head  of  the  pancreas  and  the  adjacent  duodenum; 
and  more  recently  Franke  has  demonstrated  that  the  same  is  true  of  the 
lymphatics  coming  from  the  gall-bladder.  Should  thrombo- 
lymphangeitis  occur  in  any  of  these  vessels  as  the  result  of  infection 
originating  in  the  duodenum  or  gall-bladder,  reversal  of  the  lymph- 
current  may  occur  in  the  pancreatic  lymph-channels,  in  an  effort  to 
establish  a  collateral  circulation;  and  in  this  way  infection  may  be 
propagated  from  the  gall-bladder,  bile-ducts,  or  duodenum  to  the  pan- 
creas. A  sufficiently  severe  infection  might  not  even  wait  for  reversal 
of  the  lymphatic  current,  but  might  rapidly  invade  the  pancreas  and 
infect  not  only  the  lymphatic  tissues  but  the  surrounding  structures 
as  well.     The  intrinsic  lymph-vessels  of  the  pancreas  run  in  the  inter- 


662  SURGERY  OF  THE  PANXREAS 

lobular  septa,  and  it  is  here  that  the  effects  of  this  type  of  inflammation 
should  be  most  manifest;  and  in  accordance  with  this  explanation  is  the 
fact  that  it  is  the  interlobular  form  of  pancreatitis  which  is  associated 
with  inflammatory  lesions  of  neighboring  \iscera,  in  contrast  with 
the  interacinar  sclerosis,  which,  as  pointed  out  by  Opie,  appears  to 
bear  no  such  relation  to  local  inflammation.  It  is  true  of  course 
that  the  interlobular  distribution  of  the  inflammatory  changes  might 
be  attributed  to  infection  brought  by  the  blood-vessels  or  extending 
along  the  pancreatic  ducts,  since  all  these  structures  run  in  the  inter- 
lobular tissues.  But  if  the  infection  were  propagated  by  these  channels 
it  should  be  diffusely  distributed  throughout  the  gland;  and  this  is 
not  the  case  in  the  earlier  forms  of  the  disease.  It  has  been  observed 
by  all  surgeons  that  the  earlier  forms  of  pancreatitis  found  at  operation 
in  connection  with  gall-bladder  or  duct  disease  involve  only  the  head  of 
the  pancreas  or  perhaps  only  a  portion  of  the  head;  and  the  "triangle" 
of  duct-born  infection  described  by  Desjardins  (see  page  6i8)  loses 
much  of  its  interest  when  we  consider  that  a  segmental  pancreatic 
lymphangeitis  explains  the  limitation  of  the  infection  to  the  head  of  the 
pancreas  in  a  much  more  rational  manner.  Thus  the  distribution  of 
the  pancreatic  inflammation  corresponds  to  the  lymphatic  distribution, 
which,  as  pointed  out  above,  is  irregularly  segmental.  It  does  not 
correspond  to  the  duct  distribution,  which  ramifies  by  dichotomous 
division  from  the  main  accessory  ducts.  If  the  infection  were  ductal 
in  origin,  the  gland  should  be  symmetrically  involved.  This  point 
was  emphasized  by  Arnsperger  (1911). 

The  swellings  of  the  head  of  the  pancreas  which  are  so  frequently 
encountered  by  the  surgeon  must  be  different  from  the  varieties  of 
chronic  pancreatitis  described  by  the  pathologist.  Kehr  (1909),  on 
clinical  grounds,  surmised  that  such  a  difference  exists.  "Chronic 
pancreatitis,"  which  is  characterized  by  interlobular  or  interacinar 
deposits  of  fibrous  tissue,  can  be  no  more  curable  than  chronic  nephritis 
or  cirrhosis  of  the  liver.  But  it  is  characteristic  of  the  pancreatic 
swellings  associated  with  biliary  disease  that  they  subside  with  the 
disappearance  of  the  biliary  infection;  such  swellings  therefore  must  be 
due  to  edema,  congestion,  and  absorbable  infiltrates.  The  subsidence 
of  such  a  swelling  in  the  head  of  the  pancreas  after  cure  of  the  primary 
infection  is  analogous  to  that  which  occurs  in  the  treatment  of  the 
primary  foci  of  hTiiphatic  infection  elsewhere  in  the  body.  In  many 
cases  of  what  we  term  pancreatic  lymphangeitis  it  is  possible  to  dem- 
onstrate the  chain  of  infection:  infected  gall-bladder,  enlargement  of 
the  cystic  node,  enlargement  of  the  nodes  around  the  head  of  the  pan- 


PANCREATIC    LVMPHAXGEITIS 


66r, 


creas,  and  swelling  of  the  head  of  the  pancreas,  which  corresponds  to  the 
regional  lymphatic  distribution.  Since  we  have  been  looking  for  these 
lymph-nodes,  it  is  remarkable  how  constantly  they  have  been  found  in 
this  condition.  One  node  which  appears  to  be  especially  constant  in 
position  and  enlargement  is  situated  just  to  the  right  of  the  choledochus 
where  it  passes  beneath  the  duodenum. 


\ 


Pig.  i6i. — Lymph-nodes  of  the  Bile-ducts  and  Head  of  the  Pancreas.      (Modified  from 

Cunio.) 


We  have  spoken  of  this  condition  of  pancreatic  lymphangeitis 
hitherto  chiefly  in  connection  with  gall-bladder  lesions,  because  in 
such  cases  it  is  most  easily  recognized;  but  it  is  our  belief  that  lymphatic 
infection  from  the  pylorus  and  duodenum  may  play  an  important  part 
in  the  pathogenesis  of  chronic  pancreatitis.  Not  a  few  instances  of  the 
association  of  duodenal  ulcer  and  pancreatitis  are  on  record,  while 


664  SURGERY  OF  THE  PAXCREAS 

catarrhal  duodenitis  may  also  be  a  factor.  It  is  possible  that  still  other 
organs  may  at  times  furnish  infection  to  the  pancreas;  but  at  present 
the  biliary  tract  and  the  duodenum  seem  to  be  the  chief  sources  of 
infection,  on  anatomical,  clinical  and  pathological  grounds. 

A  brief  outhne  of  the  following  case  suggests  that  disease  of  the 
appendix  may  exert  an  influence  on  the  pancreas. 

Operation  was  performed  for  gangrenous  appendicitis  in  a  female  child  who 
had  suffered  with  chUls  and  high  fev'er,  the  chills  occurring  two  or  three  times  in 
twenty-four  hours.  The  appendix  was  removed.  Chills  and  fever  persisted  and 
the  child  developed  acute  abdominal  pain.  A  second  operation  was  performed 
and  a  small  abscess  was  found  completely  encapsulated  in  the  mesentery  of  the 
ileum.  Pancreatic  lymphangeitis  was  present,  the  pancreas  itself  being  greatly 
edematous  and  infiltrated.  Death  occurred  ten  days  after  the  second  operation. 
Except  for  the  pancreatic  lymphangeitis  above  referred  to,  no  lesion  was  found  in 
the  abdomen  at  autopsy. 

The  following  are  brief  notes  of  a  case  in  which  Dr.  E.  G.  Alexander 
operated,  in  the  service  of  Dr.  H.  C.  Deaver,  Episcopal  Hospital: 

Adult  male,  aged  23,  suffering  with  acute  appendicitis,  chills  and  high  fever. 
The  appendi.x  was  removed;  no  pus  and  few  adhesions  were  found.  Seventeen 
days  after  operation  the  patient  had  a  marked  chill,  was  reoperated  on  and  a 
large  mesenteric  abscess  drained.  Death  occurred  five  months  after  the  second 
operation.  Pathologic  diagnosis  was  multiple  abscess  of  Uver,  chronic  fibroid, 
peritonitis,  post-operative  peritonitis  in  region  of  appendix,  acute  splenic  congestion, 
acute  parenchymatous  nephritis,  suppurative  cholecystitis  and  abscess  of  the  head 
of  pancreas. 

In  these  cases  it  appeared  that  the  source  of  the  peripancreatic 
and  pancreatic  inflammation  was  the  infected  appendix  and  that 
the  path  of  metastasis  was  retroperitoneal  and  through  the  lymphatics 
along  the  cystic  and  common  ducts. 

It  must  be  conceded  that  in  many  inflammatory  conditions  of  the 
abdomen  there  is  a  retroperitoneal  lymphangeitis  which  is  fraught  with 
the  possibilities  of  injury  to  the  pancreas  since  this  lies  almost  directly 
in  its  path. 

That  this  condition  of  pancreatic  lymphangeitis  has  not  been  recog- 
nized often  at  autopsy  is  no  doubt  to  be  explained  in  this  way:  the 
lesions  are  comparatively  slight,  and,  even  if  the  pancreas  is  examined 
microscopically,  they  can  be  confused  easily  with  that  autodigestion  of 
the  organ  which  ensues  at  once  after  death  and  so  often  renders  exami- 
nation of  pancreatic  tissue  unsatisfactory;  moreover  the  clinician  has 
not  called  attention  to  the  desirability  of  a  search  for  minor  pathological 


PANCREATIC    LYMPHANGEITIS  665 

alterations.  The  disease  is  not  itself  immediately  fatal;  if  it  is  relieved 
by  the  operative  treatment  instituted  the  pancreas  may  return  to  its 
normal  state;  while  if  unrelieved  it  will  progress  to  true  chronic  inter- 
stitial (interlobular)  pancreatitis,  with  deposition  of  librous  tissue. 

At  the  present  time  the  diagnosis  can  be  made  only  by  the  surgeon 
who  palpates  and  inspects  the  gland  during  operation.  The  symptoms 
are  those  of  the  primary  disease — cholecystitis,  cholelithiasis,  etc.; 
and  the  treatment  involves  only  proper  treatment  of  the  causative 
lesion. 

The  following  case  is  cited  to  show  the  extent  to  which  the  disease 
may  progress.  The  pathological  changes  are  too  far  advanced  and  the 
etiology  too  obscure  to  prove  its  lymphatic  origin  in  this  instance.  The 
glandular  involvement,  however,  is  similar  in  many  respects  to  that 
observed  by  us  in  a  considerable  number  of  earlier  cases  where  the 
considerations  just  mentioned  lead  to  the  belief  in  a  lymphatic  origin. 

D.  G.,  aged  thirty-seven  years.  Admitted  to  the  German  Hospital,  January  6, 
1912.     Died  January  ig,  igi2. 

Chief  complaint,  cramps  in  upper  abdomen,  radiating  into  flanks  and  to  right 
side  of  back. 

Family  History. — Mother  died  of  tuberculosis;  otherwise  negative. 

Personal  History. — Tea,  coffee,  and  tobacco  in  excess;  alcohol  in  moderation; 
denies  venereal  diseases.  In  March,  1910,  he  was  admitted  to  the  Pennsylvania 
Hospital  suffering  with  pain  beneath  the  right  costal  margin  radiating  to  the  back. 
The  pain  was  worse  two  or  three  hours  after  eating.  Constipation  was  a  marked 
symptom,  and  he  had  lost  considerable  weight.  At  operation  cholecystitis  was 
found  and  cholecystostomy  performed.  In  July  of  the  same  year  he  was  again 
operated  upon  for  recurrence  of  symptoms  and  cholecysto-duodenostomy  per- 
formed. In  June,  igii,  he  was  again  in  the  hospital  with  the  same  symptoms 
plus  jaundice,  chills  and  fever.  Cholelithiasis  was  diagnosticated,  but  he  was  not 
operated  upon.  In  November,  igii,  after  intermittent  attacks  resembling  those 
of  stone  in  the  common  duct  he  came  to  the  German  Hospital  and  was  again 
operated  upon.  Chronic  pancreatitis,  chronic  cholecystitis,  and  a  stone  in  the 
common  duct  were  found.  The  stone  was  forced  into  the  duodenum.  The  chole- 
cysto-duodenostomy opening  had  become  obliterated;  cholecysto-duodenostomy 
performed.  Recovery  was  uneventful,  and  he  was  improved  for  a  few  weeks,  when 
his  trouble  recurred.     More  recently  he  has  been  having  chills,  fever,  and  jaundice. 

Physical  Examination. — A  poorly  nourished  man  of  nervous  appearance.  Skin 
moderately  jaundiced.     Head  and  chest  negative. 

Abdomen:  Scar  of  old  incision  through  upper  right  rectus.  In  this  region  and 
in  the  epigastrium  there  is  marked  tenderness  on  pressure,  but  no  rigidity  or  mass. 

Urine  shows  a  very  faint  trace  of  albumin,  and  a  few  hyaline  casts,  otherwise 
negative. 

Blood:  Hemoglobin,  73  per  cent.;  erythrocytes,  4,050,000;  leukocytes,  7,300 
(polymorphonuclear  neutrophiles,  73.5  per  cent.;  lymphocytes,  26  per  cent.;  eosino- 
philes,  0.5  per  cent.) ;  coagulation  time,  8  minutes. 


666 


SURGERY   OF   THE   PANCREAS 


Stool:  Dark  green  and  praclically  non-odorous;  fluid;  neulral  reaction;  a  trace 
of  bile,  occult  blood  positive  to  benzidine  and  guaiac  tests.  Azotorrhea  and  steator- 
rhea marked. 

Cammidge  reaction  positive. 

Operation,  January  13,  191 2. — Dr.  Deaver.  Ether  anesthesia.  Excision  of  old 
scar  in  upper  right  rectus  region;  adhesions  of  stomach  and  right  lobe  of  liver  to 
incision;  hepatic  flexure  of  colon  adherent  to  right  lobe  of  liver;  great  omentum 
adherent  to  lesser  omentum:;  small  whitish  tubercles  found  on  small  intestines; 
some  adhesions  between  ascending  colon  and  parietal  peritoneum;  liver  covered 
with  a  few  whitish  nodes  which  are  subserous;  old  cholecysto-duodenostomy  still 
patulous;  head  of  pancreas  enlarged  and  hard;  felt  semicystic;  foramen  of  W'inslow, 
though  occluded,  was  forced  open;  small  glandular  enlargement  at  junction  of  the 
supra-  and  retroduodenal  portions  of  the  common  duct;  head  of  pancreas  opened  by 
inserting  scissors  and  withdrawing  them  opened  (Hilton's  method).  Much  hemor- 
rhage followed;  this  was  controlled  by  a  piece  of  selvage  gauze  and  one  suture  of 


Pig.  162. — Anterior  \'il;\v  oi  Pancreas,  with  Duct  of  Wirsung  Opened  Throughout  its 
Length  and  a  Window  in  the  Duodenum.  P  P,  Probe  from  Cystic  Duct  through  Gall- 
bladder and  Cholecysto-duodenal  Anastomosis.  P'P',  Probe  from  Dilated  Common 
Duct  into  Duodenum  through  Ampulla  of  Vater.      (Case  of  D.  G.,  page  665.) 


iodin  gut;  duodenum  incised  and  old  cholecysto-duodenostomy  proved  patent; 
much  bile-stained  material  escaped  from  opening;  head  of  pancreas  seemed  to  be 
obstructing  the  duodenum  posteriorly  from  pressure;  duodenum  closed  with  catgut 
baseball  suture  and  a  Lembert  of  linen  thread;  pancreas  at  site  of  incision  sutured 
to  parietal  peritoneum;  one  cigarette  drain  anterior  to  gastrohepatic  omentum; 
one  rubber  tube  at  foramen  of  Winslow;  another  rubber  tube  anterior  to  this  and 
wound  closed  in  layers. 

Following  the  operation  there  was  profuse  brownish  drainage  from  the  wound. 
The  jaundice  disappeared.  He  became  more  emaciated  and  gradually  weaker  and 
died  January  19,  191 2. 

Autopsy  through  the  incision  permitted  removal  of  the  pancreas  and  adjacent 
tissues.    The  head  of  the  organ  was  somewhat  smaller  than  normal,  and  appeared 


CHRONIC   PANCREATITIS  667 

necrotic.  The  selvage  gauze  in  the  pancreatic  wound  had  ulcerated  into  the  duo- 
denum at  the  site  of  the  ampulla  of  Vater.  A  fistula  existed  at  the  site  of  the  ex- 
ploratory incision  into  the  duodenum.  A  striking  feature  was  the  occurrence  of 
many  enlarged  lymph-nodes  along  the  upper  margin  of  the  pancreas.  A  few  were 
present  along  the  lower  border,  and  in  relation  to  the  head  both  anteriorly  and 
posteriorly  where  embraced  by  the  duodenum. 

Microscopically  the  tail  of  the  pancreas  was  the  seat  of  a  moderate  grade 
of  interlobular  sclerosis.  The  parenchyma  was  mostly  degenerated,  probably 
due  chiefly  to  autodigestion.  The  islands  of  Langerhans  were  intact.  The 
head  of  the  organ  showed  marked  interlobular  pancreatitis  and  an  acute  sup- 
purative process  superimposed.  The  parenchyma  was  necrotic.  The  islands 
of  Langerhans  persisted  but  were  involved  in  the  acute  necrotic  process.  A  section 
made  through  a  small  villous  patch  at  the  junction  of  the  gall-bladder  and  duodenum 
(at  the  cholecysto-duodenostomy  opening)  showed  a  Jiiarked  glandular  proliferation 
which  had  begun  to  invade  the  deeper  tissues.  The  process  had  not  e.xtended 
more  than  0.5  cm.  from  its  starting-point,  and  no  metastasis  could  be  demon- 
strated.    The  lymph  nodes  showed  chronic  and  acute  hyperplastic  lymphadenitis. 

Chronic  Interstitial  Pancreatitis. — Attention  was  first  promi- 
nently drawn  to  this  conclusion  by  Mayo  Robson  in  1900.  It  is 
infectious  in  origin;  and  as  we  have  pointed  out  in  the  preceding 
pages,  the  gall-bladder  and  bile-ducts  are  the  chief  primary  foci. 

Of  seventy-nine  patients  in  Lankenau  Hospital  with  chronic 
pancreatitis,  seventy- two  (91  per  cent.)  showed  evidence  of  infection 
in  the  bile-passages;  forty-two  (53  per  cent.)  had  gall-stones,  and 
in  thirty  (38  per  cent.)  there  was  non-calculous  inflammation.  ' 

W.  J.  Mayo  (1809)  reported  359  cases  of  pancreatitis,  86  per  cent, 
of  which  were  accompanied  by  gall-stone  disease.  Pancreatitis  in 
some  form  was  present  in  7  per  cent,  of  all  patients  where  gall-stones 
were  found  in  the  gall-bladder;  and  in  27  per  cent,  of  cases  of  stone 
in  the  common  duct  marked  pancreatitis  was  present.  This  is  in 
favor  of  the  view  held  by  Maugeret,  and  referred  to  at  page  621,  that 
the  occurrence  of  pancreatitis  results  in  stenosis  of  the  bile-ducts, 
with  resulting  arrest  of  calculi  in  the  common  and  hepatic  ducts; 
but  it  also  indicates  that  bile-duct  infection  predisposes  to  pancreatitis. 
A  vicious  circle  is  formed  in  this  way. 

Pathogenesis. — The  avenues  of  infection  in  pancreatitis  have 
been  sufficiently  discussed  (page  614).  From  all  that  is  known 
we  believe  it  is  highly  probable  that  in  the  vast  majority  of  cases 
of  chronic  pancreatitis  the  infection  occurs  through  lymph-channels 
and  that  the  earliest  stage  of  the  disease  is  a  pancreatic  lymphangeitis 
(P-  659). 

Predisposing  Causes.  Age. — The  age  at  which  pancreatitis 
is  said  to  occur  depends  upon  whether  the  reported  cases  are  from 


668  SURGERY  OF  THE  PANCREAS 

operative    or    autopsy    records.     This    is    readily  demonstrated    by 
comparing  Opie's  cases  with  ours. 

Opie  Deaver 

Under  30  years 3  cases  4  cases  (non-calculous) 

30  to  40  years 2  cases  11  cases 

40  to  50  years g  cases  1 1  cases 

50  to  60  years 11  cases  S  cases 

Over  60  years 5  cases  o  cases 


Total 30  cases  34  cases 

More  than  two-thirds  of  Opie's  cases  (autopsy  records)  occurred 
between  the  ages  of  forty  and  sixty.  In  our  series,  all  but  one  being 
operative  cases,  two-thirds  occurred  between  the  ages  of  thirty  and 
fifty. 

Sex. — In  thirty-seven  of  our  patients  with  chronic  pancreatitis 
without  gall-stones,  twenty-two  were  males  and  fifteen  females. 
Opie  reported  seventeen  males  and  thirteen  females  among  thirty 
patients.  •  Taken  in  conjunction  with  the  well-known  preponder- 
ance of  gall-stone  disease  in  women,  these  figures  indicate  that  in 
men  there  frequently  must  be  some  other  source  of  infection,  probably 
the  pylorus  and  duodenum. 

Pathology. — Opie  (1908)  divided  cases  of  chronic  interstitial  pan- 
creatitis into  two  classes,  interlobular  and  interacinar,  with  another 
form  of  degeneration,  lipomatosis,  common  to  both  classes,  and  in 
each  case  the  latest  stage  of  the  disease.  While  both  kinds  of  pancrea- 
titis consist  essentially  in  the  deposition  of  newly  formed  connective 
tissue,  the  difference  between  them  is  due  to  the  position  in  which 
the  fibrous  tissue  is  laid  down,  and  this  pathological  difference  cor- 
responds to  difference  in  etiology  and  symptomatology. 

From  a  surgical  standpoint  chronic  interlobular  pancreatitis 
is  the  only  form  of  interest,  as  interacinar  pancreatitis  is  not  amenable 
to  operative  treatment. 

Chronic  Interlobular  Pancreatitis. 

The  interlobular  connective  tissue  is  not  well  marked  in  the  normal 
pancreas,  consequently  the  lobules  are  not  sharply  defined.  In 
interlobular  pancreatitis,  however,  these  bands  of  connective  tissue 
become  greatly  increased  in  size  and  density,  accentuating  the  lobula- 
tion. A  ''typical"  case  of  chronic  interlobular  pancreatitis  has  the 
following  characteristics:  In  most  cases,  at  least  early  in  the  disease, 
the  head  of  the  pancreas  is  the  part  affected.  The  probable  reasons 
for  this  we  have  already  stated  in  the  discussion  on  pancreatic  lym- 


CHRONIC   PANCREATITIS  669 

phangeitis.  Only  very  late  is  the  entire  pancreas  involved.  The 
portion  of  the  pancreas  affected  is  enlarged  and  hard  with  a  nodular 
surface;  on  section,  tense  bands  of  fibrous  tissue  traverse  the  cut 
surfaces  in  relatively  the  same  manner  as  the  normal  interlobular 
framework,  but  the  increase  in  amount  and  density  results  in  the 
formation  of  well-marked  lobules.  From  this  classical  type,  readily 
recognizable  at  operation  or  autopsy,  all  grades  of  interlobular  change 
occur  down  to  those  cases  in  which  the  pancreas  shows  no  macroscopic 
evidence  of  disease. 

Microscopical  Examination. — The  most  striking  feature  of  this 
form  of  pancreatitis  is  the  escape  of  the  islands  of  Langerhans  from 
any  involvement  in  the  sclerotic  process.  It  is  only  very  late  in  the 
disease,  if  at  all,  that  they  are  involved.  The  disposition  of  connective 
tissue  is  most  marked  in  the  interlobular  tissue,  although,  as  the  disease 
advances,  there  is  a  certain  amount  of  invasion  of  the  parenchyma 
with  the  replacement  of  normal  parenchymatous  cells  by  fibrous 
tissue.  Later,  this  replacement  may  become  so  well  marked  that 
nothing  of  the  parenchyma  is  left  but  the  islands  of  Langerhans, 
which  appear  proportionately  in  greater  numbers  on  account  of  the 
shrinkage  of  the  connective  tissue.  Even  at  this  late  stage  the  islands 
of  Langerhans  are  intact  and  functionating,  as  is  shown  by  the  non- 
interference with  carbohydrate  metabolism.  When  glycosuria  does 
occur,  as  it  may  occasionally,  late  in  the  disease,  it  is  due  to  inter- 
ference with  the  blood  supply  of  the  islands  of  Langerhans  from  the 
pressure  of  the  contracting  fibrous  tissue  on  the  arteries. 

Lymphoid  cells,  plasma  cells  and  eosinophiles  are  numerous  in 
the  newly  formed  connective  tissue,  an  evidence  of  active  inflam- 
matory change. 

If  this  form  of  pancreatitis  was  caused  primarily  by  obstruction 
or  infection  of  the  ducts,  the  parenchyma  surely  would  be  involved 
very  early  in  the  disease,  since  this  is  the  active  secreting  portion  of 
the  pancreas  connected  with  the  excretory  ducts.  As  already  stated, 
however,  parenchymatous  changes  occur  late  in  the  disease,  the 
interlobular  connective  tissue  being  affected  long  before  the  par- 
enchyma, and  the  islands  of  Langerhans  remaining  unaffected. 

A  certain  amount  of  obstruction  of  the  pancreatic  ducts  may 
result  in  this  form  of  pancreatitis,  from  pressure  by  the  interlobular 
fibrotic  changes.  In  this  way  a  condition  is  produced  somewhat 
similar  to  that  seen  in  experimental  obstruction  of  the  pancreatic 
ducts,  which  in  animals  results  in  a  form  of  interlobular  pancreati- 
tis without  involvement  of  the  islands  of  Langerhans. 


670  SURGERY  OF  THE  PANCREAS 

Chronic  Interacinar  Pancreatitis. 

The  deposition  of  newly  formed  connective  tissue  may  take  place 
within  instead  of  between  the  lobules  of  the  gland,  with  the  result 
that  the  parenchyma  is  largely  replaced  by  fibrous  tissue,  which  is 
more  or  less  evenly  distributed  throughout  the  substance  of  the  pancreas 
without  accentuating  the  lobulation.  This  form  of  pancreatitis 
frequently  is  associated  with  sclerotic  changes  in  the  arteries;  and 
as  a  consequence  the  nutrition  of  the  islands  of  Langerhans  is  affected 
early,  and  diabetes  often  results.  The  process  sometimes  seems  to 
start  in  the  islands  of  Langerhans.  Sixty-seven  of  ninety  cases  of 
diabetes  showed  interacinar  pancreatitis,  and  in  si.xty-live  the  arteries 
of  the  pancreas  were  sclerotic  (Cecil,  191 1).  As  a  consequence  there 
is  interference  with  the  carbohydrate  metabolism  and  the  appearance 
of  glycosuria  (pancreatic  diabetes).  This  condition  contraindicated 
operation;  therefore  interacinar  pancreatitis  is  of  secondary  importance 
in  a  work  on  surgery. 

Lipomatosis. — This  condition  consists  in  the  deposition  of  large 
amounts  of  fat  in  the  connective  tissue.  It  may  occur  in  either  fomi 
of  pancreatitis.  Its  cause  and  significance  are  not  understood  and 
while  it  does  occur  in  fat  people,  obesity  is  not  a  necessary  factor  in  its 
production,  as  it  also  occurs  in  patients  who  have  lost  a  good  deal  of 
weight. 

S3rmptoms  and  Diagnosis. — The  extremes  of  opinion  in  respect 
to  the  diagnosis  of  chronic  interstitial  pancreatitis  are  represented 
by  the  pessimism  of  Opie  and  the  optimism  of  Robson  and  Cam- 
midge.  The  former  says  that  "chronic  pancreatitis  is  rarely  accom- 
panied by  such  definite  sj'mptoms  that  its  recognition  is  possible 
during  hfe."  while  the  latter  .hold  that  "from  the  information  ob- 
tained from  a  careful  examination  of  the  patient,  a  knowledge  of  the 
history  of  the  case,  and  the  results  of  a  chemical  and  microscopical 
examination  of  the  excreta,  a  correct  opinion  may  be  formed  in  a  large 
majority  of  instances."  Our  feeling  in  this  matter  is  midway  between 
the  two  extremes.  The  diagnosis  has  been  made  often  enough  to 
demonstrate  that  it  is  not  too  difftcult  to  attempt;  but  it  is  equally  true 
that  our  present  criteria  are  too  uncertain  and  inconstant  to  warrant  a 
claim  for  great  accuracy.  There  are  no  pathognomonic  symptoms. 
Chronic  pancreatitis  is  so  often  associated  with  disease  of  surrounding 
organs  that  it  is  difficult  to  separate  the  symptoms  due  to  the  accom- 
panying disease  and  those  due  to  the  pancreatitis.  Of  course  disease  of 
the  bile-ducts,  particularly  the  common  duct,  suggests  the  probable 
presence  of  pancreatic  disease,  although  the  symptoms  referable  to  each 
condition  cannot  be  dififerentiated. 


CHRONIC  PANCREATITIS  67 1 

The  factors  to  be  considered  in  making  a  diagnosis  are: 

1.  The  clinical  history. 

2.  The  physical  examination. 

3.  Special   tests  designed   to   show   disturbance  of  pancreatic 
function. 

The  following  symptoms  are  those  obtained  in  the  analysis  of  a 
series  of  cases  of  chronic  pancreatitis  (under  the  senior  author's  care) 
in  which  there  were  no  gall-stones  present  at  the  time  of  operation. 
As  about  one-third  of  these  patients  had  demonstrable  changes  in  the 
gall-bladder,  there  may  be  a  certain  admixture  of  symptoms  referable 
to  involvement  of  the  bile-passages. 

Another  point  to  be  remembered  is  that  these  cases  represent  pa- 
tients that  underwent  operation,  consequently  one  would  expect 
symptoms  to  be  more  marked  than  in  a  series  of  cases  studied  post- 
mortem. This  point  may  serve  as  a  possible  explanation  of  the  ex- 
tremely divergent  views  on  the  possibility  of  diagnosis, 'the  pathologists' 
view  being  advanced  by  Opie  and  the  surgeon's  by  Robson. 

Previous  History. — Particular  attention  should  be  paid  to  a  history 
of  previous  gastro-intestinal  trouble  or  habits  of  eating  and  drinking 
likely  to  cause  it;  also  to  the  occurrence  of  any  of  the  infectious  diseases 
habitually  followed  by  cholelithiasis.  If  disease  of  the  bile-ducts  and 
gall-bladder  has  preceded  the  pancreatic  inflammation,  the  early 
history  presents  the  symptoms  of  that  disorder,  with  perhaps  frank 
attacks  of  biliary  colic. 

The  relation  of  age  and  sex  to  chronic  pancreatitis  has  been  dis- 
cussed (page  667). 

Symptoms. — The  onset  of  symptoms  was  sudden  in  two-thirds  of  the 
cases  and  gradual  in  one-third;  but  these  figures  refer  especially  to 
exacerbations,  premonitory  symptoms  being  present  in  the  majority  of 
instances. 

The  symptoms  usually  associated  with  chronic  pancreatitis  are 
pain,  nausea  and  vomiting,  icterus,  fever  and  loss  of  weight.  These 
are  common  to  various  upper  abdominal  diseases  and  do  not  of  them- 
selves, even  when  all  are  present,  constitute  a  characteristic  symptom- 
complex. 

Pain  is  a  leading  and  most  constant  symptom.  It  was  present 
in  over  90  per  cent,  of  our  cases.  This,  of  course,  represents  opera- 
tive practice.  The  general  practitioner  must  see  many  patients 
in  whom  pain  is  absent  or  so  slight  as  to  be  negligible. 

The  character  of  the  pain  is  not  constant.     It  varies  from  a  dull 


672  StJRGERY   OF    THE    PANCREAS 

ache  with  a  sense  of  fuUness  or  oppression  in  the  epigastrium  to  sharp 
lancinating  pain  like  gall-stone  colic.  In  our  series  it  was  severe  in 
twelve  cases,  moderate  in  twenty-one.  absent  in  three  and  not  men- 
tioned in  two  histories.  X'early  one-third  of  the  patients  had  distinct 
attacks  of  colic  and  in  the  majority  of  these  the  gall-bladder  was  dis- 
eased. In  one  instance  several  stones  were  passed  before  operation 
although  no  stones  were  found  when  the  abdomen  was  opened.  It  is 
probable  therefore  that  colicky  pain  seldom  occurs  in  chronic  pan- 
creatitis unless  the  bile-passages  are  involved.  Colic  from  the  passage 
of  pancreatic  calculi  is  indistinguishable  in  character  from  biliary  colic, 
but  the  pain  of  chronic  pancreatitis  is  the  result  of  inflammatory  changes 
and  is  not  a  colic.  Yet  Archibald  (1910),  having  observed  on  several 
occasions  attacks  of  colic  in  patients  in  whom  at  operation  no  biliary 
lesions  were  demonstrable,  suggests  that  these  coUcky  pains  may  have 
been  caused  by  retrojection  of  bile  into  the  pancreatic  duct,  his  idea 
being  that  during  the  long  periods  of  fasting  which  patients  with  chronic 
pancreatitis  undergo,  the  back  pressure  of  bile  is  so  augmented  as  to 
cause  it  to  enter  the  pancreatic  duct,  though  it  is  insulhcient  to  force 
the  sphincter  of  Oddi.  except  when  this  may  become  relaxed  by  physio- 
logical stimulation  when  chyme  enters  the  duodenum  (page  38). 
Archibald  adds  that  the  condition  of  fasting  referred  to  above,  as  being 
likely  to  leave  the  sphincter  closed,  is  especially  frequent  in  chronic 
alcoholics,  among  whom  this  form  of  pancreatitis  is  so  frequent. 

According  to  Sailer  (igio)  the  administration  of  a  large  amount  of 
glucose  to  test  the  assimilation  limit  is  particularly  distressing  to 
patients  with  chronic  pancreatitis. 

Michel  (191 1)  quotes  Desjardins,  Vautrin  and  Dieulafoj'  as  stating 
that  insidiousness  is  the  dominant  characteristic  of  the  pain  of  chronic 
pancreatitis. 

The  site  of  pain  varies  as  does  the  character.  It  was  in  the 
epigastrium  in  45  per  cent,  of  the  cases  in  our  series,  beneath  the  right 
costal  margin  in  nearly  40  per  cent.,  beneath  the  left  costal  margin 
in  3  per  cent,  and  in  the  lumbar  region  in  6  per  cent. 

Radiation  of  pain  from  the  original  site  occurs  in  nearly  90  per  cent, 
of  these  cases,  to  the  epigastrium,  the  back,  the  shoulders,  etc.  Mayo 
Robson  says  that  the  attacks  of  pain  have  been  mistaken  for  those  of 
angina  pectoris. 

No  definite  relation  to  eating,  drinking,  or  any  particular  food  could 
be  determined,  a  point  of  possible  value  in  the  differential  diagnosis 
from  gall-stone  disease,  gastric  or  duodenal  ulcer. 

From   these  figures  it  is  evident   that  the  pain  occurring  in  the 


CHRONIC   PANCREATITIS  673 

course  of  chronic  pancreatitis  is  not  constant  in  character,  position 
or  radiation,  nor  distinctive  enough  in  any  way  to  differentiate  it  from 
the  pain  of  other  abdominal  diseases. 

Nausea  and  Vomiting. — More  than  haU'  of  our  patients  gave  a  his- 
tory of  vomiting  at  some  period  of  the  disease  and  about  one  in  four  was 
nauseated  but  did  not  vomit.  In  four  of  Opie's  cases,  vomiting  was  so 
persistent  and  prolonged  that  the  gastro-duodenitis  causing  it  was 
considered  the  starting-point  of  an  ascending  infection  of  the  pan- 
creatic duct  resulting  in  chronic  interlobular  pancreatitis.  In  none 
of  our  cases  was  the  vomiting  persistent,  but  the  frequency  with  which 
it  occurred  indicates  its  importance  as  a  symptom  in  the  advanced 
type  of  the  disease.  The  character  of  the  vomitus  is  not  distinctive; 
it  consists  of  stomach  contents,  bile  and  mucus. 

Jaundice. — Twenty-eight  per  cent,  of  the  patients  were  jaundiced  on 
admission,  34  per  cent,  gave  a  history  of  previous  attacks,  and  38  per 
cent,  never  had  been  jaundiced. 

Jaundice  is  not  a  symptom  of  great  value  in  differential  diagnosis 
because  of  the  various  factors  capable  of  causing  it.  Gall-stones  or 
inflammation  of  the  bile-passages  so  frequently  accompany  pancreatitis 
that  this  explanation  of  the  occurrence  of  jaundice  is  acceptable  in  a 
large  proportion  of  cases  and  Opie  considers  it  adequate  in  practically 
every  case.  However,  the  problem  is  not  so  simple.  A  certain  number 
of  cases  of  pancreatitis  with  jaundice  occur  without  any  demonstrable 
lesions  in  the  bihary  system.  The  relation  of  the  common  bile-duct 
in  its  lower  third  to  the  head  of  the  pancreas  oft'ers  a  reasonable  explana- 
tion under  these  circumstances.  In  about  two-thirds  of  instances 
the  lower  end  of  the  common  duct  passes  through  the  substance 
of  the  head  of  the  pancreas.  The  occurrence  of  jaundice  in  these 
cases  is  explained  by  the  mechanical  effect  of  swelling  of  the  gland 
causing  obstruction  to  the  flow  of  bile.  This  factor  also  explains 
the  persistence  of  jaundice  after  the  passage  of  a  stone  from  the  common 
duct.  The  stone  causes  obstruction  and  inflammatory  changes  resulting 
in  jaundice  and  pancreatic  lymphangeitis.  The  latter  in  its  turn 
causes  swelling  of  the  head  of  the  pancreas,  which  by  pressure  on  the 
common  duct  keeps  up  the  obstruction  after  the  stone  has  been  passed. 

The  fact  that  in  about  one- third  of  instances  the  common  duct 
passes  behind  and  not  through  the  head  of  the  pancreas  explains 
why  in  a  definite  proportion  of  cases  of  well-marked  pancreatitis 
jaundice  does  not  occur. 

The  degree  of  jaundice  varies  from  a  slight  tinge  to  the  "black 

jaundice"  of  the  older  writers,  which  was  supposed  to  be  diagnostic 

43 


674  SURGERY  OF  THE  PANCREAS 

of  malignant  disease.  Various  observers  have  attempted  to  differen- 
tiate jaundice  caused  by  pancreatitis  from  that  due  to  other  conditions, 
but  without  conspicuous  success.  Yet  it  seems  to  be  a  fact  that  jaun- 
dice from  pancreatic  obstruction  is  less  subject  to  variation  than  that 
due  to  stone  in  the  common  duct.  Michel  (1909)  said  the  characteris- 
tics of  jaundice  in  pancreatitis  are  variable  intensity  at  the  onset,  then 
progressive  deepening  without  special  pain.  Kehr  (1909)  said  that 
obstruction  from  a  calculus  lodged  in  the  upper  part  of  the  common  duct 
is  accompanied  by  variations  in  intensity  and  by  intermittence  of 
jaundice  because  of  the  length  and  mobility  of  the  common  duct;  but 
obstruction  in  the  lower  part  of  the  common  duct,  particularly  the 
ampulla,  causes  continuous  jaundice  without  great  remissions.  This 
latter  variety,  therefore,  is  very  difficult  to  distinguish  from  jaundice 
due  to  pancreatic  disease. 

These  observations  simply  prove  that  jaundice  is  a  symptom 
upon  which  no  great  stress  can  be  laid  in  making  a  differential  diagnosis 
of  upper  abdominal  lesions. 

When  jaundice  is  continuous  and  associated  with  rapid  wasting 
and  loss  of  strength,  the  clinical  picture  is  that  of  carcinoma  of  the 
head  of  the  pancreas.  In  13  per  cent,  of  our  cases  jaundice  was  con- 
tinuous, in  the  others,  intermittent.  Intermittent  jaundice,  pain 
and  fever  may  occur  in  the  course  of  chronic  pancreatitis  and  simulate 
stone  in  the  common  duct  with  Charcot's  hepatic  intermittent  fever. 

The  relation  of  pain  to  jaundice  in  our  cases  was  indefinite.  Four 
times  the  onset  of  jaundice  was  not  accompanied  by  pain.  Pain  pre- 
ceding the  onset  of  jaundice  may  be  due  to  gall-stone  colic,  but  as  a 
rule  the  pain  is  less  severe  and  not  of  a  colicky  character. 

Loss  of  Weight  and  Strength. — Emaciation  and  loss  of  strength 
are  fairly  constant  accompaniments  of  pancreatitis  and  always  manifest 
themselves  when  the  degree  of  sclerosis  is  sufficient  to  interfere  with 
pancreatic  function.  The  obstruction  to  the  excreting  ducts  diminishes 
the  amount  of  secretion  reaching  the  intestine,  resulting  in  imperfect 
digestion  and  mal-assimilation.  Another  factor  is  restriction  of  diet, 
voluntarily  or  by  the  adxice  of  a  physician,  in  the  attempt  to  control 
the  symptoms  of  indigestion.  At  times  impairment  of  appetite  is 
responsible  for  decreased  intake  of  food,  though  loss  of  appetite  is 
by  no  means  a  constant  accompaniment  of  pancreatitis.  It  was  men- 
tioned in  about  one-fifth  of  the  cases  in  our  series.  If  jaundice  is  present 
biliary  intoxication  ma\'  be  a  factor  in  the  production  of  emaciation. 

Loss  of  weight  was  noted  in  more  than  half  of  our  cases.  The  state 
of  nutrition  at  the  time  of  operation  was  poor  in  34  per  cent.,  good 


CHRONIC   PANCREATITIS  675 

in  25  per  cent,  while  i6  per  cent,  of  patients  were  obese;  in  24  per  cent, 
the  state  of  nutrition  was  not  mentioned.  Loss  of  strength  follows  loss 
of  weight. 

Very  rapid  loss  of  weight  may  take  place  in  some  instances,  partic- 
ularly when  jaundice  is  a  marked  feature.  Cachexia  may  be  more 
rapid  and  extreme  than  in  malignant  disease.  Moynihan  (1909) 
reported  a  case  where  a  patient  lost  26  pounds  in  three  months;  Mayo 
Robson  (1907)  reports  patients  losing  42,  55  and  no  pounds;  Chauf- 
fard  (1911),  a  patient  losing  77  pounds  in  six  months;  and  Terrier  (1906), 
a  patient  losing  16  pounds  in  one  month  and  44  pounds  in  eight  months. 

These  are,  however,  exceptions,  and  the  usual  case  does  not  exhibit 
such  marked  wasting  until  a  late  stage  of  the  disease. 

Fever. — Fever  is  not  such  a  prominent  symptom  in  the  prolonged 
course  of  chronic  pancreatitis  as  most  figures  would  seem  to  indicate. 
As  a  rule  the  temperature  is  normal.  Hyperpyrexia  is  present  only 
during  exacerbations.  Of  our  series  13  per  cent,  gave  a  history  of 
chills  and  sweating.  At  the  time  of  operation  34  per  cent,  had  a  tem- 
perature between  99°  and  100°  F.  In  10  per  cent,  it  was  between 
102°  and  103°  F. 

Bowels. — Constipation  is  the  rule;  half  of  our  patients  suffered 
with  chronic  constipation  and  in  more  than  one-third  constipation 
was  a  feature  of  the  attacks.  In  only  13  per  cent,  was  there  a  history 
of  diarrhea. 

From  this  it  must  be  seen  that  caution  must  be  used  in  employing 
as  an  aid  to  diagnosis  the  classical  description  of  "frequent  bulky 
motions,  pale  in  color,  offensive,  and  obviously  greasy."  As  stated 
by  Robson  and  Cammidge,  such  stools  are  present  only  in  advanced 
conditions.  The  stools  are  likely  to  be  clay  colored  even  when  bile 
is  present.  If  bile  is  persistently  absent  to  laboratory  tests  of  the 
duodenal  secretions  the  condition  is  more  apt  to  be  carcinoma  of  the 
pancreas  than  an  inflammatory  affection. 

Diabetes. — Glycosuria  indicates  involvement  of  the  islands  of 
Langerhans  in  the  sclerotic  process.  It  is  a  rare  symptom  in  inter- 
lobular pancreatitis  and  is  then  a  sign  that  the  destruction  of  the 
parenchyma  has  advanced  to  such  an  extent  that  the  fibrous  tissue 
has  either  encroached  directly  on  the  islands  of  Langerhans  or  has, 
by  contraction,  seriously  interfered  with  their  blood  supply.  Only 
5  per  cent,  of  the  cases  of  our  series  showed  glycosuria.  Sugar  may 
appear  in  the  urine  during  an  exacerbation  and  clear  up  on  subsidence 
of  the  inflammation  This  is  a  threat  of  oncoming  diabetes  and 
should  not  be  overlooked.     Of  equal  significance  is  the  presence  of 


676  SURGERY  OF  THE  PANCREAS 

alimentary  glycosuria,  tested  by  the  administration  of  sugar.  Drain- 
age of  the  infected  biliary  and  pancreatic  ducts  may  cause  disappear- 
ance of  glycosuria  when  it  is  associated  with  interlobular  pancreatitis 
and  is  of  recent  development. 

In  interacinar  pancreatitis  the  symptoms  of  true  diabetes  mellitus 
appear  early  in  the  course  of  the  diseae.  Recognition  of  one  of  the 
various  diseases  usually  associated  with  pancreatic  diabetes,  such 
as  arterial  sclerosis,  taken  in  conjunction  with  the  early  appearance 
of  sugar  in  the  urine,  usually  enables  a  distinction  to  be  made  be- 
tween this  form  of  pancreatitis  and  that  occurring  in  the  interlobular 
type. 

Physical  Examination. — The  physical  examination  rarely  afi'ords 
much  positive  information.  It  is  of  more  value  in  excluding  other 
conditions. 

Tumor. — During  exacerbations  there  may  be  epigastric  tender- 
ness and  rigidity  which  completely  mask  the  underlying  condition. 
In  patients  with  thin  abdominal  walls  the  swollen  head  of  the  pancreas 
sometimes  may  be  palpated  between  exacerbations  of  the  disease. 
As  a  rule,  palpation  even  of  a  considerably  enlarged  pancreas  is  im- 
possible, as  in  most  instances  the  pancreas  is  well  covered  by  the 
adjacent  organs. 

Korte  (19 11)  examined  thirty  cadavers  with  reference  to  this 
point.  In  twenty  the  pancreas  was  completely  covered,  while  in 
ten  there  was  some  part  covered  with  omentum  only.  In  six  there 
was  ptosis  of  the  colon  with  exposure  of  a  portion  of  the  head  of  the. 
pancreas  between  the  liver  and  colon;  in  two  it  was  exposed  in  the 
median  cleft  of  the  liver;  in  the  other  two  there  was  marked  gastro- 
ptosis  and  the  pancreas  could  be  palpated  directly  beneath  the  gastro- 
hepatic  omentum.  In  palpating  through  the  abdominal  wall  these 
slight  exposures  of  pancreatic  tissue  rarely  are  sufficient  to  give  definite 
results. 

When  a  mass  is  demonstrable  it  may  be  referable  to  an  enlarged 
gall-bladder  or  a  cancer  of  the  head  of  the  pancreas  as  well  as  to  chronic 
interstitial  pancreatitis.  Even  when  the  abdomen  is  open  the  differen- 
tiation between  carcinoma  and  chronic  pancreatitis  may  be  exceedingly 
difficult. 

Enlargement  of  the  gall-bladder  has  been  observed  in  a  number 
of  cases,  but  in  our  cases  it  was  not  detected  prior  to  the  operation. 
The  liver  was  noted  as  enlarged  in  about  25  per  cent,  of  the  cases. 

Tenderness. — As  most  of  our  patients  were  operated  on  during 
or  just  after  some  exacerbation  of  symptoms  there  was  a  degree  of 


CHRONIC   PANCREATITIS 


677 


tenderness  present  in  most  of  them.  In  eight  no  tenderness  was 
elicited.  In  the  remainder  tenderness  was  found  below  the  right 
costal  margin  in  twenty;  beneath  the  left  in  three;  in  the  mid-epigas- 
trium in  eleven;  over  Mayo  Robson's  point^  in  three;  and  in  one 
severe  case  it  was  general.  Rigidity  was  observed  in  the  right  hypo- 
chondrium  in  nine  cases  and  over  the  epigastrium  in  three.  There 
was  moderate  distention  in  six  cases. 

There  is  then  no  constant  point  or  area  to  which  tenderness  is 
limited  in  cases  of  chronic  pancreatitis,  although  various  authors 
have  described  them.  Desjardins 
(1898)  described  a  point  5-6  cm. 
above  the  umbilicus  on  a  line  drawn 
between  it  and  the  gall-bladder  area, 
as  the  point  on  the  abdomen  rep- 
resenting the  position  where  the  duct 
of  Wirsung  enters  the  duodenum. 
Chauffard  and  Rivet  (1911),  instead 
of  describing  a  fixed  point,  name  the 
area  corresponding  to  the  head  of 
the  pancreas  the  pancreatico-hepatic 
area.  This  area  occupies  the  lower 
part  of  an  angle  of  45  degrees  formed 
by  the  midline  and  a  line  drawn  up 
and  to  the  right  from  the  umbilicus 
(Fig.  163). 

We  think  no  dependence  can  be 

.  .  Fig.   163. — The  "  Pancreatic  Point"  of 

placed  on  these  or  smular  points  and     Desjardins  and  the  •■  Pancreatico-hepatic 

areas  of  tenderness  in  differentiating    ^'^^"  °^  Chaui=fard  and  Rivet. 
conditions  of  the  upper  abdomen. 

Blood  Examination. — The  blood  frecjuently  shows  secondary 
anemia  which  seldom  is  grave,  but  may  become  so  if  surgical  in- 
tervention is  delayed  too  long.  In  about  one-half  of  our  cases  the 
hemoglobin  was  below  80  per  cent.,  and  the  erythrocytes  below 
4,000,000.  A  moderate  leukocytosis  was  present  during  a  few  of 
the  more  acute  exacerbations.  Generally  the  numerical  ratio  of  the 
leukocytes  was  unaltered. 

Special  Tests  to  Show  Disturbances  oj  Pancreatic  Function. — The 
number  and  variety  of  laboratory  aids  to  diagnosis  show  that  none 
of  them  is  infallible.  The  most  important  have  been  discussed  at 
page  626. 

'  This  is  a  point  "just  above  and  to  the  right  of  the  umbilicus"  (1907). 


678  SURGERY  OF  THE  PANCREAS 

Examination  of  Feces. — The  results  of  examinations  of  the  feces 
in  our  cases  have  convinced  us  that  functional  tests  of  pancreatic 
activity  have  not  yet  reached  a  stage  which  warrants  much  dependence 
upon  them. 

The  reaction  of  the  feces  in  pancreatic  disease  may  be  markedly 
acid;  normally  there  is  an  amphoteric  reaction. 

Examination  of  the  Duodenal  Contents. — This  is  a  much  surer 
method  for  determining  the  functional  activity  of  the  pancreas,  than  is 
analysis  of  the  feces.  If  bile  and  pancreatic  ferments  are  present,  it  is 
not  likely  that  the  pancreas  is  seriously  diseased.  If,  however,  the 
accessory  pancreatic  duct  is  patulous,  pancreatic  secretion  may  reach 
the  duodenum  even  in  cases  of  jaundice  from  obstruction  at  the  papilla 
of  \'ater,  with  pancreatitis. 

Examination  of  the  Urine. — It  is  advisable  to  collect  a  twenty- 
four-hour  specimen.  Cammidge  (1911)  recommended  a  simple  mixed 
diet  for  two  or  three  days  beforehand,  rather  than  any  special  test 
diet,  as  the  idea  is  to  measure  the  capacity  for  digesting  normal  food. 
Routine  examination  includes  tests  for  the  following:  Albumen,  sugar, 
urobilin,  acetone,  diacetic  acid,  the  amount  of  ammonia  nitrogen,  the 
results  of  the  pancreatic  reaction,  and  the  presence  of  calcium  oxalate 
crystals  microscopically  (Cammidge) . 

The  "pancreatic"  or  Cammidge  Reaction  (1901). — As  is  well  known 
this  reaction  consisted  in  the  demonstration  in  the  urine,  when 
treated  by  a  rather  complex  chemical  procedure,  of  certain  crystals  of  a 
definite  morphology  and  certain  solubility  characteristics,  but  of  un- 
known composition,  although  they  were  thought  to  be  a  derivative  of 
pentose,  probably  an  osozone. 

For  some  years  a  great  deal  was  written  about  the  Cammidge 
reaction.  Opinions  differed  as  to  its  value.  Some  considered  it 
valueless  as  an  aid  to  diagnosis,  others  considered  it  more  or  less  useful 
and  still  others  apparently  depended  on  the  results  of  the  "pancreatic" 
reaction  more  than  on  any  other  factor.  At  the  present  day  very  few 
if  any  surgeons  attach  any  importance  to  it  whatever. 

Glycosuria. — This  is  a  sign  that  appears  late  in  interlobular  pan- 
creatitis and  is  of  grave  significance.  Sugar  may  appear  in  the  urine 
during  exacerbations  and  disappear  in  the  intervals.  Ahmentary 
glycosuria  is  another  important  indication  of  pancreatic  insufficiency 
that  should  be  looked  for. 

Calcium  Oxalate. — The  presence  of  the  characteristic  crystals 
of  calcium  oxalate  is  said  to  be  a  confirmatory  sign  of  pancreatic 
insufficiency. 


CHRONIC   PANCREATITIS  679 

Diagnosis. — Undue  prominence  seems  to  be  given  in  the  symp- 
tomatology of  chronic  pancreatitis  to  the  description  and  discussion  of 
the  various  laboratory  methods  for  determining  interference  with  the 
function  of  the  pancreas.  This  may  be  taken  as  an  indication  of  the 
views  on  diagnosis.  The  confidence  of  clinicians  in  their  abihty  to 
diagnosis  this  condition  is  directly  expressed  by  their  faith  in  the  accur- 
acy and  reliability  of  the  various  tests  for  pancreatic  function. 

From  the  symptoms  and  physical  signs,  localization  of  the  disease 
to  the  pancreatico-hepatic  region  almost  always  can  be  made,  but  in  the 
diflerentiation  of  chronic  pancreatitis  from  disease  of  the  bile-ducts,  or 
in  the  diagnosis  of  pancreatitis  accompanying  or  resulting  from  gall- 
stone disease  there  always  is  a  large  amount  of  doubt,  as  to  the  possi- 
bility of  accurate  localization,  in  the  minds  of  those  cHnicians  whose 
experience  with  the  disease  has  been  greatest. 

There  are  no  pathognomonic  signs  of  chronic  interlobular  pan- 
creatitis, the  suggestive  factor  being  the  association  of  various  symp- 
toms and  physical  signs,  which  have  been  sufficiently  discussed.  We 
do  not  consider  the  positive  diagnosis  of  chronic  interlobular  pan- 
creatitis possible,  as  we  have  never  seen  a  case,  diagnosed  clinically 
chronic  pancreatitis,  operated  upon  and  demonstrated  to  have  this 
condition  as  the  primary  and  most  important  lesion.  It  is  true  that  the 
presence  of  pancreatitis  either  alone  or  in  conjunction  with  other  lesions 
may  be  strongly  suspected,  but  the  diagnosis  cannot  be  made  with  the 
same  degree  of  certainty  as  in  gall-stones,  duodenal  ulcer  or  appendici- 
tis. In  a  very  few  instances,  none  of  which  have  come  under  our  direct 
observation,  marked  emaciation  showing  some  grave  metabolic  change, 
with  intermittent  constipation  and  diarrhea,  and  large  stools  with 
much  undigested  fat  have  pointed  quite  directly  to  the  existence  of  a 
pronounced  pancreatic  lesion.  In  the  vast  majority  of  cases,  however, 
these  symptoms  are  not  sufficiently  marked  to  attract  notice. 

The  differentiation  from  gall-stone  disease  is  very  difficult  if  not 
impossible  in  the  greater  number  of  patients.  Fortunately  treatment 
is  the  same  and  the  patient  does  not  suffer  from  the  surgeon's  inability 
to  localize  the  various  lesions  causing  the  symptoms.  The  presence  of 
pancreatitis  may  be  considered  highly  probable  if  the  patient  has  had 
symptoms  referable  to  the  bile-passages  persisting  over  a  long  period. 

In  cases  of  chronic  jaundice,  the  presence  or  absence  of  bile  in  the 
duodenal  contents  may  aid  greatly  in  the  diagnosis.  Even  in  advanced 
cases  of  chronic  pancreatitis  obstruction  of  the  common  duct  is  rarely 
absolute,  consequently  some  bile  escapes  into  the  intestines.  A  stone 
in  the  common  duct,  unless  it  completely  blocks  the  outlet,  acts  in  a 


68o  SURGERY  OF  THE  PANCREAS 

similar  manner.  On  the  other  hand,  carcinoma  of  the  head  of  the  pan- 
creas, as  a  rule,  causes  absolute  obstruction  and  allows  no  bile  to  escape. 
Carcinoma  of  the  bile-ducts,  or  of  the  gall-bladder  causing  secondary 
obstruction  of  the  ducts  may  cause  the  same  absolute  occlusion  and 
prevent  the  escape  of  the  bile.  \'ery  often  after  the  abdomen  is  opened 
and  the  pancreas  examined  directly  by  sight  and  touch,  it  is  impossible 
to  diagnosticate  carcinoma  of  the  head  of  the  pancreas  from  chronic 
interstitial  pancreatitis  localized  to  the  same  region. 

Chronic  cholangeitis  without  gall-stones,  and  chronic  appendicitis 
of  the  type  manifesting  itself  chiefly  or  solely  by  upper  abdominal 
symptoms,  may  also  be  mistaken  occasionally  for  chronic  pancreatitis. 

Prognosis. — It  does  not  appear  that  the  existence  of  chronic  pan- 
creatitis as  a  complication  of  biliary  tract  disease  materially  increases 
the  immediate  mortality  of  operative  treatment,  unless  the  pancreatitis 
has  passed  beyond  the  curable  stage.  (See  Tables  at  pp.  504,  505,  684.) 
Xor  does  it  seem  that  the  expectation  of  life  is  materially  less.  In  other 
words,  the  prognosis,  both  immediate  and  remote,  in  early  cases  of 
chronic  pancreatitis  is  much  the  same  as  in  diseases  of  the  biliary  tract, 
and  varies  with  the  complications  present  in  the  gall-bladder  and 
bile-ducts. 

Treatment.  Medical  Treatment. — In  mild  cases  where  the  diag- 
nosis is  extremely  uncertain,  medical  treatment  should  be  continued 
if  improvement  occurs.  It  is  not  improbable  that  many  of  the  so-called 
"stomach  complaints,"  catarrh,  etc.,  are  mild  cases  of  pancreatic  lym- 
phangeitis  that  end  in  recovery.  That  these  patients  may  be  benefited, 
by  a  by  a  "  cure  "  at  one  of  the  famous  springs  is  highly  probable.  But 
too  great  delay  in  resort  to  surgical  measures  is  mistaken  policy, 
especially  when  the  diagnosis  of  the  usual  underlying  biliary  complaint 
is  certain,  since  chronic  pancreatitis,  when  once  it  has  reached  the  stage 
of  fibrous  deposit,  is  incapable  of  being  cured,  although  possibly  the 
still  further  progress  of  the  disease  may  be  arrested  by  timely  operation. 

Surgical  Treatment. — Surgical  treatment  of  chronic  pancreatitis 
aims  at  the  accomplishment  of  three  things:   ' 

1.  Removal  of  the  underlying  cause. 

2.  Prevention  of  further  involvement  of  the  pancreas. 

3.  Cure  of  the  pancreatic  disease  present. 

Removal  of  the  underlying  cause  is  not  always  easy,  as  it  is  no  easy 
matter  to  determine  it  in  all  instances.  When,  however,  there  is  evi- 
dence of  infection  of  the  biliary  system,  meeting  these  conditions  is 
sufficient  to  do  away  with  the  pancreatic  disease  in  the  majority  of 
instances. 


CHRONIC   PANCKEATITIS  68 1 

In  cases  of  biliary  infection,  calculous  or  otherwise,  operative  treat- 
ment involves  more  or  less  prolonged  drainage  of  the  biliary  tract,  and 
this  furnishes  the  correct  mode  of  meeting  the  pancreatic  condition. 

The  surest  and  most  advantageous  method  of  providing  drain- 
age and  at  the  same  time  eliminating  the  main  source  of  infection  is 
by  cholecystectomy.  Drainage  of  the  common  duct  should  then  be 
established. 

There  is  no  doubt  that  the  pancreas  may  be  drained  through  the 
opening  in  the  common  duct.  In  certain  cases  the  discharge  is  pecu- 
liarly irritating  to  the  skin,  often  causing  excoriation.  The  presence 
of  pancreatic  ferment  is  demonstrated  by  the  digestion  of  blood-serum 
and  starch  in  alkaline  solution.  This  we  have  done  to  prove  that 
draining  the  common  duct  also  drains  the  pancreas.  These  findings 
were  obtained  in  cases  where  the  patency  of  the  outlet  of  the  common 
duct  was  insured  by  the  passage  of  a  good-sized  gall-stone  explorer 
through  the  ampulla  into  the  duodenum.  When  the  pancreatic  duct 
does  not  open  into  the  sinus  of  Vater,  this  avenue  for  drainage  of  the 
pancreas  is  not  open;  but  the  operation  is  productive  of  good  in  that  the 
primary  focus  of  infection  in  the  gall-bladder  is  abolished,  and  the  ac- 
companying lymphangeitis  of  the  pancreas  cured. 

At  times  when  the  closure  of  the  common  duct  is  complete  and 
likely  to  be  lasting,  a  cholecystenterostomy  may  be  best.  Robson 
and  Kehr  are  of  the  opinion  that  drainage  by  cholecystenterostomy 
will  cure  97  per  cent,  of  cases  of  chronic  pancreatitis.  Much  as  we 
dislike  to  disagree  with  such  eminent  authorities,  we  are  stillpartial  to  ex- 
ternal drainage.  As  a  general  rule  this  permits  subsidence  of  the  swelUng 
of  the  pancreas  and  a  re-establishment  of  the  functions  of  the  ducts. 
This  drainage  should  be  maintained  for  several  weeks  at  the  very  least. 
If  the  gall-bladder,  not  the  choledochus,  has  been  drained  it  is  often 
diihcult  to  keep  the  fistula  from  closing  too  soon,  but  in  cases  of  marked 
pancreatic  disease  the  sinus  may  continue  to  discharge  bile  for  months. 
This  should  not  discourage  either  the  patient  or  the  surgeon,  provided 
the  presence  of  bile  in  the  feces,  even  in  slight  amount,  can  be  ascer- 
tained. Vautrin  (1908)  had  to  wait  nine  months  in  one  case  for  the 
choledochus  to  become  permanently  patent  and  for  the  biliary  fistula 
to  close;  Kehr,  Korte  and  others  have  had  to  wait  three  or  four  months 
for  the  sinus  to  close.  The  prolonged  drainage  is  beneficial;  many  pa- 
tients have  had  recurrence  of  symptoms  when  the  sinus  closed  and  it 
has  had  to  be  reopened.  It  is  our  practice  in  cases  of  chronic  pan- 
creatitis, always  to  pass  a  sound  through  the  common  duct  into  the 
duodenum,  to  make  certain  that  the  passage  is  permeable.     Only  when 


682  SURGERY  OF  THE  PANXREAS 

at  operation  the  obstruction  of  the  common  duct  is  very  marked,  and 
the  head  of  the  pancreas  very  hard,  do  we  think  it  proper  to  resort  to 
cholecystenterostomy  even  as  a  secondary'  operation.  Just  how  long 
the  cholecysto-intestinal  anastomosis  remains  patulous  is  a  question, 
for  in  a  few  cases  reoperation  has  demonstrated  that  the  opening  has 
closed.  Cholecysto-duodenostomy  is  an  operation  having  a  higher 
mortaHty  than  cholecystectomy,  which  fact  should  be  borne  in  mind 
when  deciding  the  operation  to  be  adopted  in  the  individual  case. 

The  problem  of  the  treatment  of  pancreatitis  when  the  gall-bladder 
seems  to  be  practically  normal  is  a  more  difficult  one.  In  many  of 
these  cases  close  observation  shows  that  the  gall-bladder  exhibits 
some  interstitial  thickening  and  possibly  opacity  of  the  serous  coat. 
Such  gall-bladders  frequently  contain  thick  tarry  looking  bile,  many 
times  containing  micro-organisms,  perhaps  anaerobic.  These  are 
probably  cases  of  mild  hepatic  infection,  with  inconspicuous  involve- 
ment of  the  gall-bladder,  or  perhaps  as  suggested  by  Archibald's  experi- 
ments are  cases  in  which  retrojection  of  nearly  normal  bile  in  small 
amounts  occurs  into  the  pancreatic  duct.  Drainage  is  as  efficacious 
in  these  as  in  cases  which  show  distinct  pathological  changes  in  the 
bile-tract.  In  some  of  these  cases  the  origin  of  the  trouble  is  in  pyloric 
disease,  and  Finney's  pyloroplasty,  gastro-enterostomy,  or  other 
operation  may  be  indicated.  When  no  other  lesion  can  be  discovered 
Vautrin  advocated  attacking  the  pancreas  directly;  especially  did 
he  urge  drainage  of  the  retropancreatic  tissues  after  exposing  this  region 
by  mobilization  of  the  duodenum  (Fig.  164).  In  one  case  he  uses  the 
thermo-cautery  to  liberate  the  common  duct  from  its  position  within  the 
dense  pancreatic  head. 

The  means  employed  to  remove  the  underlying  cause  of  pancreati- 
tis are  also  best  adapted  to  prevent  extension  of  the  process  and  to  cause 
a  restitution  to  normal,  so  far  as  this  is  possible,  of  pathological  lesions 
already  present.  In  pancreatic  lymphangeitis,  proper  drainage  of  the 
bihary  tract  reduces  to  a  minimum  the  probability  of  an  interstitial 
fibrotic  change  being  superimposed  upon  it. 

As  we  have  already  indicated,  we  think  cholecysto-duodenos- 
tomy rarely  or  never  is  indicated  for  the  treatment  of  chronic  pan- 
creatitis. If  the  common  duct  is  patulous,  it  is  extremely  improbable, 
as  indicated  by  Archibald's  experiments,  that  this  operation  diverts 
the  bile  from  its  natural  channel;  and  it  is  our  belief  that  it  should  very 
rarely  be  employed  as  a  primary  operation.  In  those  very  rare  cases 
of  chronic  pancreatitis  where  a  biliary  sinus  persists  indefinitely  after 
drainage  of  the  gall-bladder,  cholecysto-duodenostomy  may  be  employed 


CHRONIC   PANCREATITIS 


683 


with  propriety,  and  in  most  cases  with  complete  relief  of  symptoms.  But 
the  danger  of  an  ascending  cholangeitis  always  exists,  and  the  operation 
should  not  be  adopted  without  mature  consideration.  If  the  gall- 
bladder has  been  inadvisedly  removed  at  a  previous  operation,  one  of 
the  other  methods  of  restoring  the  continuity  of  the  bile-passages 
must  be  employed  (page  510). 


Pig.  164.- 


-Exposure  o£  the  Head  of  the  Pancreas  and  Common  Bile-duct  after  MobUization 
of  the  Duodenum.      (After  Guibe.) 


The  whole  question  of  treatment  for  chronic  pancreatitis  resolves 
itself  into  an  earnest  endeavor  promptly  to  treat  upper  abdominal 
disease  by  appropriate  surgical  means  when  medication  has  been  in- 
effectual or  when  the  symptoms  point  to  a  pathological  condition 
not  amenable  to  the  ordinary  therapeutic  measures. 

The  following  table  contains  a  summary  of  the  operations  done  by 
the  senior  author  at  theLankenau  Hospital  during  the  past  ten  years: 


684 


SURGERY   OF    THE    PANCREAS 

Operations  for  Chroxic  Pancreatitis  (igio-1920) 
(Lankenau  Hospital) 


Operation 


Associated  lesions 


Cases 


Deaths 


Cholecystostomy . 


Cholecystostomy  and  marsupiali- 
zation. 

Cholecystostomy  and  choledocho- 
stomy. 


Cholecystectomy . 


Carcinoma  gallbladder. . . 
Cholecystitis,  chronic. . . 

Calculus 

Pancreatic  lymphangitis 
No  other  lesion 

Total 

Cj'st,  pancreas,  calculus 

Calculus 

Cholecystitis,  chronic 
No  other  lesion ,    . 

Total 


Cholecystectomy  and  choledochos- 
tomy. 


Choledochso  tomy . 


Calculus 

Pancreatic  lymphangitis 

Cholecystitis,  chronic 

Cholecystitis,  chronic,  pancre- 
atic lymphangitis 

Cholecystitis,  chronic,  cirrhosis 

liver 

Total 

Calculus 

Cholecystitis,  chronic 


Total. 


Calculus . 

No  other  lesion . 

Total 


Cholecystoduodenostomy. 


Calculus 

Cyst,  pancreas 

Cholecystitis,  chronic 

Cirrhosis  liver,  ulcer  duodenal, 

nephritis 

No  other  lesion 

Total 


Hepaticoduodenostomy 

Pancreatostomy 

Pancreatostomy  and  choledochos- 
tomy 


No  other  lesion . 
Calculus.  . 
Calculus. 

Total 

TOT.\L. 


16 

3 


3 

0 

44 

I 

I 

0 

14 

•  r 

2 

0 

I 

0 

17 

I 

6 


I 

0 

48 

4 

32 

2 

2 

0 

34 

2 

S 

I 

2 

I 

ID 

2 

6 

I 

22 

2 

I 

0 

I 

0 

I 

0 

3 

0 

179 


12  (6.7<$i) 


symptoms  of  pancreatic  calculi  685 

Pancreatic  Calculi 

In  contradistinction  to  gall-stones,  pancreatic  calculi  are  of  very- 
infrequent  occurrence.  Johnston  collected  thirty-five  cases  in  1883, 
and  by  1904  Lazarus  found  only  a  total  of  fifty-seven  cases  on  record. 
Little  that  is  definite  is  known  of  the  factors  which  cause  their 
formation.  This  aspect  of  the  question,  as  well  as  certain  aspects 
of  the  clinical  pathology  of  the  subject  have  been  discussed  at  page  621. 

Symptoms. — As  is  the  case  with  all  other  chronic  diseases  of  the 
upper  abdomen,  pancreatic  calculi  may  exist  for  years  without  causing 
any  definite  symptoms  or  physical  signs.  Cases  have  been  reported 
frequently  where  stones  previously  unsuspected  have  been  found 
at  autopsy.  There  is  nothing  distinctive  in  the  group  of  symptoms 
usually  associated  with  pancreatic  calculi — pain,  nausea  and  vomiting, 
jaundice,  glycosuria,  steatorrhea,  azotorrhea  and  digestive  disturbances. 

Pain. — This  varies  in  severity  from  an  indefinite  dull  ache  or 
sense  of  pressure,  to  attacks  of  acute  colic  scarcely  to  be  distinguished 
from  biliary  colic.  And  just  as  "biliary  colic"  may  be  caused  by 
violent  peristaltic  contractions  of  the  gall-bladder  and  ducts,  in  the 
absence  of  all  calculi;  so  it  is  probable  that  "pancreatic  colic"  does 
not  always  depend  on  the  presence  of  calculi  in  the  pancreatic  ducts. 
In  many  cases  of  acute  pancreatitis  there  is  a  history  of  previous 
attacks  of  epigastric  pain,  which  may  have  been  due  to  small  hemor- 
rhages or  possibly  to  violent  peristaltic  contraction  of  the  pancreas. 
In  situation  and  radiation  the  pains  usually  are  indistinguishable  from 
those  accompanying  biliary  colic,  as  is  evidenced  by  the  fact  that 
pancreatic  calculi  have  been  so  frequently  diagnosed  "gall-stones." 
The  persistence  of  colic,  after  an  operation  for  gall-stones,  may  be 
due  to  calculi  in  the  pancreas  (cases  of  Korte  and  Kiimmell).  This, 
however,  is  a  very  rare  event.  The  pain  is  said  to  be  more  severe 
in  the  left  epigastrium  and  to  radiate  to  the  left  scapular  region  instead 
of  the  right;  but  in  other  cases  the  pain  starts  in  the  back  and  radiates 
around  the  side  or  straight  through  the  body  (Kinnicutt,  1902).  Nau- 
sea and  vomiting  are  constant  accompaniments  of  the  severe  attacks 
of  pain,  as  is  the  case  in  biliary  colic.  Rigors  and  collapse  may  also 
occur.  Subsequent  to  these  attacks  of  pain,  calculi  or  fragments 
of  calculi  may  be  recovered  from  the  feces.  Analysis  of  these  stones 
shows  the  usual  composition  of  pancreatic  calculi;  as  noted  at  page  622, 
they  consist  largely  of  calcium  carbonate  and  phosphate.  A  stone 
that  has  been  lodged  long  in  the  ampulla  of  Vater  may  become  coated 
with  bile-salts  and  biliary  coloring  matter  until  it  resembles  a  gall- 


686  SURGERY  OF  THE  PANCREAS 

stone,  but  the  nucleus  of  the  stone  presents  the  characteristic  com- 
position. Such  a  stone  may  set  up  jaundice  from  obstruction  of  the 
common  duct.  This  is  not  an  uncommon  symptom  in  connection 
with  pancreatic  lithiasis.  It  has  the  usual  characteristics  of  obstruc- 
tive jaundice.  If  the  stone  is  passed  jaundice  is  temporary,  but  if 
the  stone  lodges  the  jaundice  remains  and  probably  increases.  Jaun- 
dice may  be  due  not  to  blocking  of  the  duct  by  a  stone  in  the  ampulla 
of  Vater,  but  to  an  associated  cholelithiasis  or  bile-duct  infection, 
or  to  obstruction  from  pressure  by  the  head  of  the  pancreas,  since 
in  association  with  pancreatic  lithiasis  there  always  is  a  certain  amount 
of  pancreatitis.  Occasionally  this  is  of  extreme  degree;  then  there 
may  be  symptoms  referable  to  the  gastro-intestinal  tract  resulting 
from  pancreatic  indigestion,  with  steatorrhea  and  azotorrhea  and 
other  characteristic  changes  found  in  association  with  chronic  inter- 
stitial pancreatitis. 

Intermittent  or  permanent  glycosuria  occurs  in  about  half  of 
the  cases,  and  is  to  be  attributed  to  involvement  of  the  islands  of 
Langerhans  in  the  sclerotic  process.  Alimentary  glycosuria  may  be 
present  occasionally.  Flatulence,  indigestion,  loss  of  weight,  etc., 
are  to  be  referred  to  the  accompanying  pancreatitis  rather  than  to 
the  calculus. 

Robson  and  Cammidge  call  attention  to  the  fact  that  calcium  oxa- 
late crystals  are  present  in  the  urine  in  over  40  per  cent,  of  cases 
without  jaundice,  but  in  only  6  per  cent,  of  jaundiced  cases. 

The  most  important  characteristic  about  pancreatic  calculus  is 
that  it  is  composed  of  material  impenetrable  to  the  X-rays  and  there- 
fore can  be  demonstrated  on  an  X-ray  plate.  If  shadows  are  found 
by  the  X-ray,  or  if  a  stone  is  passed  having  the  characteristics  of 
pancreatic  calculus,  the  diagnosis  is  simple.  In  other  cases  it  is 
tentative  and  can  be  cleared  up  only  by  operation. 

Diagnosis. — Diagnosis  depends  on  X-ray  examination.  Gall- 
stones are  not  often  shown  in  a  skiagram.  The  composition  of  pan- 
creatic stones,  if  any  are  passed,  is  diagnostic,  as  they  are  composed 
of  calcium  salts  without  cholesterin  or  biliary  coloring  matter.  Other 
than  these  two  signs  there  is  no  method  of  arriving  at  a  definite  diag- 
nosis. Lichtheim,  in  1894,  made  a  diagnosis  of  pancreatic  calculi 
in  a  patient  who  suffered  from  epigastric  colics,  and  later  developed 
diabetes  and  characteristic  diarrhea;  and  autopsy  confirmed  the  diag- 
nosis. Pepper,  as  long  ago  as  1882,  made  the  diagnosis  of  pancre- 
atic calculus  in  a  patient  under  his  care,  but  this  was  not  confirmed 
by   the   passage  of  calculi,   nor  did  the  patient  come  to  autopsy. 


TREATMENT  OF  PANCREATIC  CALCULI  687 

Kinnicutt  (1902)  collected  seven  cases  in  which  the  diagnosis  was 
made  during  life,  and  Cipriani  (1898)  reported  another  case  apparently 
overlooked  by  Kinnicutt.  Glaessner  (1913)  made  the  diagnosis  in 
four  patients,  two  of  whom  passed  calculi  with  the  characteristics  of 
pancreatic  concretions;  and  Einhorn  (191 6)  made  the  diagnosis  in 
two  patients,  but  in  only  one  of  these  cases  was  the  diagnosis  con- 
firmed by  passage  of  a  calculus. 

Treatment. — Operation  was  suggested  by  Korte  in  1898;  it  is  the 
only  rational  method  of  treatment.  The  stone  cannot  be  absorbed 
and  while  one  may  be  passed  occasionally,  usually  there  are  more 
left.  As  the  condition  is  so  often  associated  with  chronic  pancreatitis 
the  latter  also  calls  for  operation,  at  which  time  the  stone  can  be 
removed.  Very  often  operation  is  undertaken  because  of  a  mistaken 
diagnosis  of  cholelithiasis  or  cholecystitis. 

The  treatment  of  colic  is  symptomatic  as  in  gall-stones. 

The  operation  consists  in  cutting  down  through  the  substance 
of  the  gland  and  removing  the  stone  wherever  it  may  be.  In  operation 
on  the  head  of  the  pancreas  it  may  be  necessary  to  mobilize  the  duo- 
denum to  gain  access  to  the  affected  area  which  may  thus  be  approached 
from  its  dorsal  surface  (Fig.  164).  In  some  cases  the  calculus  or  calculi 
may  be  exposed  just  to  the  left  of  the  descending  portion  of  the  duo- 
denum by  an  incision  in  the  upper  layer  of  the  transverse  meso-colon. 
If  the  stones  are  in  the  body  or  toward  the  tail  of  the  pancreas,  they 
are  exposed  best  by  division  of  the  gastro-colic  omentum  (Fig.  160) 
or  by  the  intercolo-epiploic  route  (Fig.  11).  Cut  surfaces  of  the 
pancreas  unite  after  suture  despite  the  presence  of  pancreatic  juice  on 
the  surfaces  of  the  wound;  but  in  every  case  efficient  drainage  must 
be  provided  down  to  the  site  of  the  sutured  area. 

La  Couture  and  Charbonnel  (1914)  collected  17  operations  for  stone 
in  the  pancreas  including  their  own  case:  the  results  are  known  in  16 
instances,  5  patients  dying  soon  after  operation  (34  per  cent,  mor- 
tality) ,  10  surviving  and  being  in  good  health  when  reported  from  3  to  4 
months  later,  and  i  dying  of  diabetes  several  years  after  ODeration. 
In  Link's  (1911)  patient,  constituting  the  seventh  operation  on  record, 
a  formal  pancreatostomy  was  performed.  Finding  the  pancreas  even 
up  to  its  tail  filled  with  innumerable  small  stones,  making  it  feel  like  a 
bag  of  fine  sand,  he  exposed  it  through  the  transverse  meso-colon. 
He  next  tore  through  the  posterior  parietal  peritoneum  covering  the 
pancreas,  seized  the  tail  of  the  pancreas,  and  commenced  its  enucleation 
just  as  if  it  were  a  pyosalpinx  covered  with  adhesions.  He  found  it  a 
comparatively  easy  task  to  free  the  gland  as  far  to  the  patient's  right  as 


688 


SURGERY    OF    THE    PANCREAS 


the  superior  mesenteric  arter\'.  It  was  now  possible  to  bring  the  tail  of 
the  pancreas  out  of  the  abdominal  wound.  Sponges  were  placed  in  its 
bed  to  arrest  hemorrhage,  which  was  not  at  all  alarming;  the  pancreatic 
branches  of  the  splenic  artery  were  not  ligated.  After  isolating  the 
pancreas  by  gauze,  it  was  split  in  the  middle  Hne  for  about  two-thirds  of 
its  length.  This  opened  the  dilated  duct  of  Wirsung,  which  was 
found  to  be  filled  with  small  facetted  stones  along  its  entire  length. 
The  stones,  except  those  in  the  head  of  the  gland,  were  removed; 


^g^^S^m^i^. 


Fig.  165. — Pancreatostomy.     (Link.) 


and  a  drainage  tube  was  laid  in  the  dilated  duct  of  Wirsung,  projecting 
several  inches  from  the  tail  of  the  pancreas.  The  gland  was  then 
closed  around  the  tube  with  a  continuous  suture  of  No.  i  chromic 
catgut  (Fig.  165).  After  stitching  the  opening  in  the  meso-colon  to  the 
body  of  the  pancreas,  the  great  omentum  was  sutured  over  the  sutured 
area  of  the  pancreas.  A  gauze  drain  was  placed  beneath  the  pancreas, 
to  protect  it  from  the  small  intestines.  Finally  the  abdominal  wound 
was  closed  around  the  tail  of  the  pancreas,  which  emerged  at  the  lower 
angle  of  the  incision.     Pancreatic  fluid  was  discharged  freely  at  first 


INJURIES    OF    THE   PANCREAS  689 

(about  750  cc.  daily  during  the  first  week),  but  as  the  pancreatic  in- 
flammation subsided  the  secretions  resumed  their  natural  course  into 
the  duodenum.  Several  months  after  operation  the  drainage  was 
slight,  and  the  patient  had  resumed  her  usual  active  life. 

In  Dowd's  patient  (1915),  not  included  in  the  statistics  of  La 
Couture  and  Charbonnel,  recovery  followed  the  evacuation  of  a  pan- 
creatic abscess,  which  contained  30  or  more  concretions.  Though  these 
concretions  were  composed  chiefly  of  cholesterol  and  cholesterolesters, 
had  practically  no  ash,  and  cast  no  X-ray  shadows,  Dowd  considered 
them  pancreatic  in  origin;  and  there  was  certainly  nothing  to  suggest 
that  they  might  be  migrated  biliary  calculi.  The  patient  continued  in 
good  health  one  year  after  the  operation. 

Injuries  of  the  Pancreas 

Uncomplicated  injuries  of  the  pancreas  are  very  rare.  This  is 
to  be  explained  by  its  deep  situation,  almost  completely  covered  by 
other  abdominal  organs.  Korte  (1898)  showed  that  in  twenty  out  of 
thirty  cadavers  the  pancreas  was  entirely  covered  by  neighboring 
viscera.  On  account  of  its  inaccessibility,  rupture  is  less  seldom 
uncomplicated  than  either  gunshot  or  stab  wound.  Fowelin  (191  r) 
refers  to  twenty-nine  cases  of  isolated  ruphire  of  the  pancreas.  The 
patient  under  his  own  care  was  the  only  case  he  could  find  of  uncom- 
plicated stab  wound;  the  instrument  entered  from  behind,  to  the  left  of 
the  spine.  Becker  (1904)  appears  to  have  reported  the  only  uncompli- 
cated gunshot  u<ound  of  the  pancreas  on  record ;  the  bullet  passed  to  the 
left  of  the  stomach  through  the  gastro-splenic  omentum.  Both  Fowe- 
lin's  and  Becker's  patients  recovered  after  prompt  operation. 

The  symptoms  of  pancreatic  injury  are  in  no  way  characteristic, 
and  an  accurate  diagnosis  before  opening  the  abdomen  usually  is  im- 
possible. Usually  it  is  the  complicating  injuries  (liver,  stomach,  etc.) 
which  produce  recognizable  symptoms,  and  the  lesion  of  the  pancreas  is 
discovered  only  incidentally.  Wohlgemuth  and  Benczur  pointed  out 
(1910)  that  there  is  an  increase  in  the  amount  of  diastase  in  the  blood 
and  urine  within  a  few  hours  after  experimental  or  pathological  obstruc- 
tion of  the  pancreatic  duct;  and  Noguchi  (1912)  suggested  that  chemical 
tests  for  diastase  may  be  of  value  in  determining  whether  or  not  the 
pancreas  has  been  injured  in  cases  of  abdominal  traumatism. 

The  prognosis  depends  upon  the  promptness  of  operation  and  very 
largely  upon  the  presence  of  complicating  injuries.  Among  twenty-nine 
cases   of   isolated   rupture   of   the   pancreas    mentioned    by    Fowelin, 


690  SURGERY  OF  THE  PAXCREAS 

seven  died  without  operation;  twenty-two  were  operated  on,  with 
fourteen  recoveries  and  eight  deaths,  a  mortality  of  36.3  per  cent. 
Diehl  rigii)  collected  twenty-two  cases  of  gunshot  ivounds  of  the 
pancreas,  only  one  of  which  was  uncomplicated:  among  these  patients 
six  died  without  operation;  sixteen  were  operated  on,  with  nine  re- 
coveries and  seven  deaths  a  mortality  of  43.7  per  cent.  7/  the  wound 
of  the  pancreas  is  not  discovered  at  tJie  time  of  operation,  death  nearly 
always  is  the  result  of  overlooking  it.  This  was  the  cause  of  death  in 
three  out  of  the  above  seven  fatal  cases  and  doubtless  contributed 
to  the  similar  outcome  in  President  McKinley's  case.  If  operation  is 
postponed,  fat  necrosis  and  retroperitoneal  hemorrages  may  be  found 
when  the  abdomen  is  opened;  the  case  then  will  closelj'  resemble  one 
of  acute  pancreatitis. 

Treatment. — Immediate  laparotomy  is  indicated  as  in  all  injuries 
of  the  abdominal  viscera.  Usually  the  incision  is  made  in  or  near  the 
median  line,  for  purposes  of  exploration.  In  every  case  in  which 
there  is  any  possibility,  even  remote,  of  pancreatic  injury,  the  pancreas 
should  be  explored,  either  through  the  gastro-colic  or  the  gastro-hepatic 
omentum.  The  former  is  the  preferable  route,  as  giving  better 
exposure.  As  directed  at  page  295  the  incision  in  the  gastro-colic 
omentum  should  be  at  least  8  cm.  long,  and  should  pass  below  the  gas- 
tro-epiploic  vessels  (Fig.  160,  p.  651).  Bleeding  from  the  pancreas 
should  be  checked  by  gauze  packing,  unless  the  point  is  freely  accessible 
when  suture  may  be  attempted.  But  even  where  the  injury  has  been 
securely  sutured,  the  surgeon  should  not  neglect  to  drain  the  injured 
region.  Should  a  pancreatic  fistula  develop,  the  discharge  may  be 
much  lessened  and  healing  accelerated  by  putting  the  patient  on  Wohl- 
gemuth's  antidiabetic  diet  (page  658). 


CHAPTER  XXII 
TUMORS  OF  THE  PANCREAS 

Solid  Tumors  of  the  Pancreas 

These  include  carcinoma,  sarcoma  and  adenoma,  of  which  carci- 
noma is  the  most  common. 

Carcinoma  of  the  Pancreas. — Various  statistics  have  been  reported 
indicating  the  frequency  of  carcinoma  of  the  pancreas.  But  figures 
derived  from  records  published  before  1900  are  not  entirely  trust- 
worthy, as  until  the  general  recognition  of  chronic  pancreatitis  which 
followed  Mayo  Robson's  researches,  many  cases  of  the  latter  disease 
were  regarded  as  carcinomatous.  Without  histological  examination 
it  is  difficult  to  distinguish  one  from  the  other.  With  these  limita- 
tions in  mind,  the  following  classical  statistics  may  be  quoted:  among 
,^3,788  cases  of  carcinoma  in  males  Bashford  found  primary  carcinoma 
of  the  pancreas  in  526;  and  among  50,660  cases  in  females,  the  tumor 
was  primary  in  the  pancreas  in  474.  This  shows  a  distinctly  greater 
frequency  of  primary  carcinoma  in  the  male  sex. 

Secondary  carcinoma  of  the  pancreas  is  of  little  interest  to  the  sur- 
geon. It  seldom  is  the  result  of  metastasis;  in  almost  all  cases  it  is  due 
to  extension  from  neighboring  organs,  particularly  the  stomach.  Secon- 
dary carcinoma  has  been  considered  much  more  common  than  the  prim- 
ary form,  only  two  of  Eppinger's  nineteen  cases  being  primary.  But 
Hale  White's  statistics  (1897)  do  not  uphold  these  figures,  and  Ferguson 
(1910)  says  that  primary  carcinoma  of  the  pancreas  is  more  common 
than  secondary.  If  Oser's  statement  (1903)  is  true  that  10  per  cent, 
of  all  cases  of  primary  carcinoma  of  the  stomach  involve  the  pancreas 
secondarily,  there  can  be  no  doubt  that  secondary  growths  are  more 
common  than  primary. 

Age. — Carcinoma  of  the  pancreas  is  a  disease  of  middle  or  advanced 
life.  In  nearly  all  reported  cases  the  patient  has  been  over  forty 
years  of  age.  Cases  occurring  in  childhood  have  been  reported  by 
Bohn,  Kuhn,  Simon  and  Dutil.  Their  cases  were  respectively  seven 
months,  two  years,  thirteen  years  and  fourteen  years  of  age. 

Sex. — As  indicated  already,  carcinoma  of  the  pancreas  is  more 
common  in  men  than  women,  the  relation  being  about  three  to  two, 
much  the  same  ratio  which  obtains  in  cases  of  chronic  pancreatitis. 

691 


692  TUMORS    OF    THE    PAXCREAS 

Mirallie  (1893)  reported  100  cases  of  primary  pancreatic  cancer,  sixty- 
nine  being  in  men  and  thirty-seven  in  women.  Oser  (1903).  including 
Mirallie's  cases,  reported  246  in  men  to  142  in  women.  Among  the 
sixteen  cases  of  primary  carcinoma  arising  in  the  body  of  the  pancreas, 
studied  by  Leriche  (1910),  eleven  occurred  in  males,  and  only  five  in 
females. 

Pathology. — While  diffuse  growths  occasionally  occur,  primary 
carcinoma  usually  is  of  small  size.  This  fact  explains  why  primarj^ 
involvement  of  the  head  of  the  pancreas  with  metastasis  to  the  liver 
is  so  often  mistaken  for  primary  carcinoma  of  the  Hver,  the  original 
growth  in  the  pancreas  being  overlooked  on  account  of  its  small  bulk. 
When  a  pancreatic  cancer  grows  to  a  large  size,  invades  neighboring 
structures  and  forms  extensive  adhesions,  the  starting  point  of  the 
growth  is  not  easily  determined. 

In  primary  carcinoma  the  head  of  the  gland  is  the  most  frequent 
site  of  growth,  although  the  body,  tail  or  whole  gland  may  be  involved. 
Oser  in  sixty-eight  cases  found  the  following  distribution:  head,  thirty- 
nine;  whole  organ,  nineteen;  tail,  four;  head  and  body,  three;  body 
and  tail,  one;  head  and  tail,  one.  In  Mirallie's  106  cases  the  head  was 
the  site  of  the  growth  in  eighty-two.  In  Segre's  cases  (1888)  the  distri- 
bution was  as  follows:  head,  thirty-five;  entire  gland,  nineteen;  body, 
two;  tail,  one,  Robson  and  Cammidge  give  the  following  percentages: 
head  62  per  cent.;  tail  5.5  per  cent.;  body  3.5  per  cent.;  diffuse  growth 
29  per  cent. 

The  point  of  origin  of  the  growth  usually  determines  its  type 
(Hulst  1905).  If  it  arises  in  the  epithelium  of  the  e.xcretorj^  ducts 
it  develops  into  a  cylindrical  celled  tumor  of  the  adenocarcinomatous 
form.  Letulle  contends  that  a  carcinoma  springing  from  the  ducts 
of  Wirsung  is  composed  of  solid  alveoli  of  spheroidal  and  not  cylindrical 
cells.  Olivier  (1894)  reported  a  case  in  which  the  cells  of  the  tumor 
apparently  arose  directly  from  the  ducts  and  the  growth  was  of  the 
spheroidal-celled  soHd  alveolar  type  without  the  central  lumen  seen  in 
adenocarcinoma.  Hulst  thinks  that  these  spheroidal-celled  tumors 
with  solid  alveoli  take  their  origin  from  the  glandular  epithelium. 

Whatever  the  origin  of  these  two  forms  there  usually  is  developed 
sufficient  fibrous  tissue  to  make  them  hard  and  firm.  The  great 
majority  of  pancreatic  carcinomata  are  of  the  scirrhous  variety.  Occa- 
sionally the  growths  are  very  cellular,  forming  a  tumor  of  encephaloid 
type.  Columnar-celled  tumors  may  undergo  colloid  degeneration, 
several  having  been  reported. 

No  connection  has  ever  been  definitely  determined  between  the 


CARCINOMA  693 

islands  of  Langerhans  and  the  origin  of  carcinoma.  Hillier  and  Goodall 
(1904)  described  a  form  of  carcinoma  supposed  to  arise  from  the  islands 
of  Langerhans.  These  differ  from  the  other  forms  in  the  great  irregu- 
larity of  their  cells.  Olivier  believes  that  some  of  the  so-called  cases 
of  primary  carcinoma  of  the  pancreas  arise  in  the  duodenum  from  the 
glands  of  B  runner. 

Sooner  or  later  the  growth  of  a  carcinoma  of  the  pancreas  encroaches 
on  one  of  the  excretory  ducts  and  causes  complete  obliteration  of  its 
lumen.  This  results  in  the  development  of  a  chronic  interstitial 
pancreatitis  in  the  area  drained  by  the  affected  duct.  Moreover,  the 
tumor  itself,  as  already  noted,  is  surrounded  by  a  reactionary  growth 
of  connective  tissue. 

Carcinomatous  degeneration  in  chronic  interstitial  pancreati- 
tis is  spoken  of  as  a  possible  comphcation  by  Hulst,  but  has  not  yet 
been  proved  to  occur. 

Neighboring  organs  may  be  involved  from  primary  carcinoma 
of  the  pancreas  by  metastasis,  extension,  or  the  formation  of  adhesions. 

Metastasis  occurs  in  the  liver  as  a  rule.  When  it  is  extensive 
the  determination  of  the  site  of  the  primary  growth  is  extremely  diffi- 
cult. This  applies  particularly  to  cases  of  carcinomatosis  said  to 
arise  from  primary  tumors  of  the  pancreas. 

The  position,  size,  and  direction  of  the  growth  of  the  tumor  deter- 
mine the  organs  involved  by  extension  or  adhesions.  Carcinoma  of  the 
head  of  the  pancreas  encroaches  on  the  common  bile-duct,  and  causes 
steadily  increasing  obstruction  until  the  lumen  is  completely  obliterated. 
This  blocking  of  the  common  duct  is  evidenced  by  progressively  deepen- 
ing jaundice,  which  usually  is  associated  with  enlargement  of  the  gall- 
bladder, unless  previous  gall-stone  disease  has  caused  thickening  and 
shrinkage  from  fibrous  change.  The  stomach  and  duodenum  from 
their  relations  to  the  pancreas  are  naturally  the  areas  to  suffer  most 
frequently.  Obstruction  to  the  duodenum  or  pylorus  causing  dilata- 
tion of  the  stomach,  ulceration  into  the  duodenum  or  stomach,  com- 
pression of  the  transverse  colon  or  stomach  and  of  various  large  vessels 
in  the  abdominal  cavity,  and  even  compression  of  the  left  ureter  causing 
hydronephrosis,  have  all  been  described  as  resulting  from  carcinoma  of 
the  pancreas. 

Glycosuria  is  not  a  frequent  complication  but  when  it  does  occur 
it  indicates  involvement  of  the  islands  of  Langerhans,  either  in  the 
chronic  pancreatitis  resulting  from  the  growth  or  in  the  tumor  itself. 

Symptoms. — In  carcinoma  of  the  pancreas  there  are  no  pathog- 
nomonic  symptoms.     Following   the   original   clinical  picture   drawn 


694  TUMORS    OF    THE    PANCREAS 

by  Bard  and  Pic  (1888),  it  was  considered  for  a  long  time  that  steadily 
increasing  jaundice,  enlargement  of  the  gall-bladder  and  rapid  emacia- 
tion constituted  a  characteristic  syndrome  or  group  of  symptoms,  which 
indicated  carcinoma  of  the  head  of  the  pancreas.  Now,  however,  it  is 
generally  recognized  that  this  syndrome  may  result  from  any  condition 
which  causes  obstruction  at  the  papilla  of  Vater.  In  carcinoma  of  the 
pancreas  it  is  only  when  the  growth  is  in  the  head  of  the  gland  that  this 
obstruction  results,  so  there  are  necessarily  cases  that  do  not  exhibit 
the  so-called  characteristic  symptoms.  On  the  other  hand  various 
conditions,  such  as  carcinoma  of  the  bile-ducts,  chronic  interstitial 
pancreatitis,  carcinoma  of  the  gall-bladder,  etc.,  may  cause  obstruction 
of  the  choledochus  and  of  the  duct  of  Wirsung,  and  thus  give  rise  to  this 
same  group  of  symptoms.  A  diagnosis  of  carcinoma  of  the  pancreas, 
therefore,  must  be  made  with  a  certain  degree  of  reserve;  and  only  after 
careful  consideration  of  the  history,  physical  signs  and  laboratory 
findings  in  each  individual  case. 

Jaundice. — In  carcinoma  of  the  head  of  the  pancreas  the'  common 
duct  is  steadily  compressed  and  eventually  occluded  by  the  growth, 
jaundice  resulting.  The  characteristic  feature  of  the  jaundice  is 
steady  progress  without  intermission  or  remission,  differing  in  this 
particular  from  that  caused  by  a  stone  in  the  duct,  which  is  subject 
to  variation,  as  obstruction  is  seldom  so  complete  as  to  prevent  abso- 
lutely the  passage  of  bile.  Complete  obstruction  is  shown  by  the 
persistent  absence  of  bile  and  pancreatic  ferments  in  the  duodenal 
contents.  Occlusion  of  the  common  duct  by  cancer  of  the  choledochus. 
or  of  the  papilla  of  Vater,  or  by  extension  from  cancer  of  the  gall- 
bladder or  pylorus  gives  rise  to  the  same  type  of  jaundice,  and  it  is 
indistinguishable  from  that  caused  by  carcinoma  of  the  head  of  the 
pancreas. 

The  manufacture  of  bile  continues  in  spite  of  the  obstruction  and 
the  jaundice  gradually  deepens  until  it  becomes  the  "black  jaundice" 
of  older  writers. 

If  the  body  or  tail  of  the  pancreas  is  affected  the  disease  may  run 
its  whole  course  without  causing  jaundice.  As  a  symptom  of  carcinoma 
of  the  pancreas,  jaundice  is  peculiar  to  growths  involving  the  head  of 
the  gland,  the  only  position  in  which  the  tumor  can  compress  the 
common  duct. 

Extension  to  the  head  of  the  pancreas  or  metastasis  to  the  liver 
or  the  lymph-nodes  in  the  gastro-hepatic  omentum  is  necessary  before 
jaundice  will  arise  in  cases  of  carcinoma  of  the  body  or  tail  of  the 
pancreas. 


CARCINOMA 


69s 


Enlargement  of  the  Gall-bladder.  —  If  carcinoma  is  the  primary 
condition  and  there  has  been  no  previous  gall-stone  disease  or  duct 
inflammation;  in  other  words,  if  at  the  time  of  onset  of  obstructive 
jaundice  the  gall-bladder  is  normal,  back  pressure  on  the  ducts  causes 
distention  of  the  gall-bladder  from  the  accumulation  of  bile.  As  the 
obstruction  increases  and  the  pressure  becomes  greater,  no  more  bile 
can  reach  the  gall-bladder  and 
the  continuing  distention  is  due 
to  secretion  of  mucus. 

If  there  has  been  previous  in- 
flammation from  stones  or  non- 
calculous  infection  the  deposit 
of  fibrous  tissue  in  and  around 
the  walls  of  the  gall-bladder  in- 
terferes with  its  elasticity  and  it 
is  consequently  incapable  of  dis- 
tention. In  these  cases  the  gall- 
bladder is  small  and  contracted 
irrespective  of  the  amount  of 
back  pressure. 

Pain. — Opinions  differ  in  re- 
gard to  the  occurrence  and  the 
degree  of  pain.  Opie  says,  "Pain 
is  one  of  the  earliest  and  most 
common  symptoms."  On  the 
other  hand  Robson  and  Cam- 
midge  say,  "Pain  is  usually 
absent  or  unimportant;"  while 
Robson  and  Moynihan  say,  "In 
one-half  the  cases  at  least,  the 

suffering   is   exquisite."       Chauf-      „   ^'°-      166.  — Obstructive     jaundice     with 

Enlargement   of  the  Liver   and  Gall-bladder, 
fard      (1908)       called      particular      Presumably  from   Carcinoma  of  the  Head  of 
i.       .•  .  •  the  Pancreas.      An  Inoperable    Case.     From 

attention    to    very    severe  crises     ^  Patient  in  the  Lankenau  Hospital. 

of    abdominal    pain,   which  he 

described  as  a  veritable  visceralgia.  He  described  the  patients  as 
sitting  with  flaccid  abdomen,  bending  forward  to  their  knees,  and 
unable  to  eat  anything.  From  these  contradictory  statements  it 
may  be  inferred  that  all  varieties  in  character  and  severity  of  pain 
occur;  and  that,  while  pain  may  be  a  conspicuous  feature,  it  is  not  a 
necessary  factor  in  the  clinical  picture  of  a  case  of  pancreatic  carcinoma. 
In  cases  which  have  come  under  our  own  observation,  pain,  while  seldom 


696  TUMORS    OF    THE    PANCREAS 

a  prominent  symptom,  has  rarely  been  entirely  absent.  \'arious  explan- 
ations of  the  cause  of  the  pain  have  been  given.  Continuous  pain 
increasing  in  severity  until  death  is  ascribed  to  pressure  on  the  celiac 
gangha.  Colicky  pain  is  supposed  to  be  due  to  obstruction  of  the 
duct  of  Wirsung  or  the  common  duct  setting  up  attacks  of  true  coHc. 
When  the  head  of  the  pancreas  is  involved,  the  usual  seat  of  pain  is 
in  the  epigastrium  or  right  hypochondrium,  from  which  situations  it 
may  radiate  to  the  back  or  shoulder.  When  the  growth  originates  in 
the  body  of  the  gland,  Leriche  (1910)  says  the  earhest  pain  is  in  the 
left  hypochondrium. 

Loss  of  Weight  and  Strength.— 'E&Tly  in  the  course  of  the  disease 
the  loss  of  weight  and  strength  is  very  striking,  and  this  continues 
progressively  and  rapidly  until  the  patient  dies  from  exhaustion. 
Death  seldom  is  delayed  more  than  a  few  months  after  the  ap- 
pearance of  jaundice.  Pancreatic  cancer  is  said  to  be  the  most 
rapidly  fatal  of  all  forms  of  malignant  disease.  The  entire  dura- 
tion of  the  malady,  from  the  recognition  of  the  tirst  symptoms,  seldom 
exceeds  a  year. 

Digestive  Disturbances. — These  are  of  two  kinds:  (i)  those  due 
to  obstruction  of  the  duodenum  or  pylorus,  causing  s^Tnptoms  of 
stricture;  and  (2)  those  due  to  interference  with  pancreatic  digestion. 
The  former  give  the  usual  picture  of  pyloric  obstruction,  anorexia, 
distress  and  distention  after  eating,  and  delayed  vomiting,  together 
with  the  well-known  physical  signs  and  laboratory  findings  of  gastric 
dilatation  from  obstruction. 

If  the  duct  of  Wirsung  is  occluded  to  such  an  extent  that  little  or 
no  pancreatic  juice  reaches  the  intestine,  the  usual  evidences  of  pan- 
creatic insufficiency  are  found.  There  is  early  loss  of  weight  and  strength 
much  greater  than  that  usually  caused  by  the  growth  of  a  malignant 
tumor. 

The  changes  that  occur  in  the  feces  when  pancreatic  juice  does  not 
reach  the  intestine  have  been  described  at  page  626.  Briefly,  they  are 
increase  in  the  amount  of  unabsorbed  fat  in  the  feces  from  the  normal 
of  5  per  cent,  to  50  per  cent,  or  more  (in  cancer  of  the  head  of  the  pan- 
creas the  unabsorbed  fat  in  the  feces  may  amount  to  90  per  cent,  of 
that  ingested) ;  diminution  in  the  percentage  of  split  fat  from  the  normal 
of  70-80  per  cent,  to  as  low  as  1 5  per  cent.  Even  in  those  cases  in  which 
there  is  no  increase  above  normal  in  the  actual  amount  of  fecal  fat, 
there  is  still  a  diminution  in  the  proportion  of  split  fats  to  40  per  cent,  or 
less.  These  findings  and  their  significance  have  been  discussed  in  re- 
lation to  diagnosis  (page  627). 


CARCINOMA  697 

Tumor. — Tenderness  is  unusual,  but  may  occasionally  be  present 
and  interfere  with  palpation.  In  the  majority  of  cases  no  mass  referable 
to  the  pancreas  is  palpable,  the  tumor  usually  being  small  and  confined 
to  the  head  of  the  gland.  While  it  is  true  that  the  greater  number  of 
malignant  growths  of  the  pancreas  are  fixed,  this  is  not  a  universal 
rule  by  any  means.  Although  the  pancreas  is  retroperitoneal,  it  is 
invested  by  loose  areolar  tissue  which  permits  considerable  motion, 
and  unless  it  is  anchored  by  inflammatory  or  malignant  adhesions, 
mobility  is  marked.  Mobility  of  a  tumor,  therefore,  does  not  neces- 
sarily rule  out  a  pancreatic  origin.  Body  and  tail  tumors  are  more 
likely  to  be  movable  than  those  arising  in  the  head  of  the  gland.  As 
a  rule,  however,  malignant  growths  are  either  too  small  to  be  felt  or 
are  firmly  fixed  by  adhesions. 

In  thin  patients  with  relaxed  abdominal  walls  any  considerable 
enlargement  of  the  pancreas  can  be  detected,  but  it  takes  a  compara- 
tively large  tumor  to  be  recognized  as  such.  When  palpable  it  usually 
transmits  pulsation  from  the  aorta;  and  if,  as  in  Poncet's  case(i89o) 
there  is  also  a  murmur  the  lesion  may  be  mistaken  for  an  aortic  aneurysm. 
In  one  of  Giovanni's  patients  (1916),  both  of  whom  presented  this 
symptom,  aneurysm  of  the  celiac  axis  was  present.  Mirallie  (1893) 
reported  that  there  was  a  palpable  tumor  in  one-fourth  to  one-fifth  of 
his  113  cases.  A  tumor  was  palpable  in  nine  out  of  fourteen  cases  of 
carcinoma  of  the  body  or  tail,  analyzed  byLeriche  (1910);  usually  the 
mass  presented  through  the  gastro-hepatic  omentum,  displacing  the 
stomach  downward.  Although  the  pancreas  itself  usually  cannot  be 
palpated  there  often  is  an  epigastric  tumor  due  to  the  distended  gall- 
bladder. In  rare  instances  two  tumors  have  been  felt,  one  the  pan- 
creatic growth  and  the  other  the  distended  gall-bladder.  An  enlarged 
gall-bladder  is  easily  felt  as  a  rounded,  smooth  tumor  which  is  just 
beneath  the  abdominal  wall  and  moves  with  respiration.  In  fifty 
eight  out  of  sixty-two  cases  of  obstruction  of  the  common  bile-duct  due 
to  carcinoma  of  the  pancreas  reported  by  Eckhn  (1896)  there  was 
recognizable  enlargement  of  the  gall-bladder. 

The  Hver  has  no  distinctive  features,  its  size  varying. from  normal 
to  marked  enlargement,  depending  upon  the  degree  and  character 
of  the  secondary  involvement.  Considerable  increase  in  the  size  of  the 
liver  is  to  be  expected  in  the  late  stages  of  the  disease  (Fig.  166). 

Glycosuria  occurs  in  a  certain  proportion  of  cases.  It  appears 
when  the  growth  has  advanced  to  such  an  extent  that  it  has  destroyed 
the  greater  number  of  the  islands  of  Langerhans;  as  is  the  case  in 
chronic  interlobular  pancreatitis,   the  islands  of  Langerhans  persist 


698  TUMORS    OF    THE    PANCREAS 

for  some  time  after  the  parenchyma  has  been  destroyed,  so  that  the 
appearance  of  sugar  in  the  urine  usually  is  a  late  development  if  it 
occurs  at  all.  Miralhe  (1893)  reported  glycosuria  present  in  thirteen 
of  fifty  cases.  Both  alimentary  glycosuria  and  transient  glycosuria  have 
been  reported,  but  the  mere  presence  of  sugar  in  the  urine  does  not  serve 
to  differentiate  the  form  of  pancreatic  disease  causing  it. 

In  cases  of  continued  jaundice  there  always  is  a  tendency  to  hemor- 
rhage. In  cancer  of  the  head  of  the  pancreas,  gastric,  intestinal, 
subcutaneous,  and  even  nasal  and  oral  hemorrhages  are  not  uncommon 
when  hepatic  involvement  has  produced  portal  obstruction.  Spon- 
taneous hemorrhage  usually  is  not  serious,  but  that  which  occurs 
after  operation  and  which  is  due  to  changes  in  the  blood,  is  distinctly 
dangerous.  Persistent  and  uncontrollable  postoperative  oozing  fre- 
quently is  fatal  even  in  those  cases  where  nothing  but  an  exploratory 
incision  has  been  undertaken. 

The  analysis  of  stomach  contents  is  comparatively  of  little  value 
in  differentiating  pancreatic  from  other  upper  abdominal  growths, 
but  in  doubtful  cases  useful  confirmatory  evidence  is  occasionally 
obtained  by  analysis  of  the  duodenal  contents. 

Left-sided  hydronephrosis,  ascites,  edema  of  the  legs  and  en- 
largement of  the  spleen  sometimes  are  present  as  pressure  symptoms. 
Another  pressure  symptom  which  was  mentioned  at  page  697  is  aortic 
pulsation  with  a  murmur.  Chylous  ascites  has  been  reported;  it  is 
due  to  rupture  of  the  thoracic  duct. 

Elevation  of  temperature  results  only  when  an  intercurrent  in- 
fection arises. 

The  clinical  course  of  a  case  of  carcinoma  of  the  pancreas  is  remark- 
able for  its  rapid  progress  to  a  fatal  termination.  The  interference 
with  pancreatic  digestion,  the  jaundice,  and  the  cachexia  from  a 
malignant  tumor  combine  to  make  this  one  of  the  most  rapidly  fatal 
of  malignant  diseases.  Death  usually  ensues  within  six  to  eight 
months  after  the  appearance  of  jaundice  but  it  may  be  delayed  for 
two  or  even  four  years  after  the  onset  of  the  earliest  symptoms. 

Diagnosis. — In  a  typical  case  of  primary  carcinoma  of  the  head 
of  the  pancreas  the  diagnosis  can  be  made  with  a  fair  degree  of 
certainty,  but  unfortunately  not  at  an  early  period  of  the  malady 
unless  the  growth  arises  very  close  to  the  main  excretory  duct  and 
rapidly  invades  the  papilla  of  Vater  or  compresses  the  common  bile 
duct.  The  patient,  usually  over  forty  years  old,  complains  for  a 
vague  period  of  upper  abdominal  symptoms  having  no  localizing 
character.     After   a   longer   or   shorter   time   jaundice   appears   and 


CARCINOMA  699 

painlessly  and  continuously  deepens;  the  gall-bladder  enlarges  and 
the  patient  loses  weight  and  strength  very  rapidly.  Pain  may  or 
may  not  be  a  conspicuous  feature.  The  persistent  absence  of  bile 
and  pancreatic  juice  from  the  duodenum  is  a  valuable  confirmatory 
sign,  and  indicates  complete  obstruction.  The  feces  may  show  signs 
characteristic  of  failure  of  pancreatic  digestion  due  to  the  absence 
of  pancreatic  juice.  A  tumor  connected  with  the  pancreas  seldom 
can  be  recognized.  When  there  is  such  a  tumor  its  relations  may 
be  determined  by  inflating  the  stomach  and  colon.  Theoretically 
this  should  completely  obscure  a  tumor  of  the  pancreas,  but  from 
the  number  of  cases  reported  where  operation  was  undertaken  for 
other  conditions,  it  is  evident  that  pancreatic  tumors  often  exhibit 
characteristics  common  to  various  abdominal  tumors.  The  size  of 
the  liver  is  of   comparatively  little   value  in   differential   diagnosis. 

The  main  factors  on  which  a  diagnosis  of  cancer  of  the  head  of 
the  pancreas  is  based  are  progressive  jaundice,  enlargement  of  the 
gall-bladder,  rapid  loss  of  weight  and  strength,  and  persistent  absence 
of  bile  and  pancreatic  juice  from  the  duodenum.  Such  a  clinical 
picture  indicates  complete  obstruction  of  the  common  duct,  and 
carcinoma  of  the  head  of  the  pancreas  is  the  commonest  cause  of 
such  obstruction;  yet  other  causes  cannot  always  be  excluded,  espe- 
cially carcinoma  of  the  common  bile-duct  or  the  papilla  of  Vater  caus- 
ing coincident  obstruction  of  the  duct  of  Wirsung.  Carcinoma  of  the 
hepaticus  causes  obstructive  jaundice  but  there  is  no  pancreatic  insuffi- 
ciency; and  even  when  the  duct  of  Wirsung  is  obstructed  by  a  growth, 
pancreatic  insufficiency  may  not  develop  if  the  accessory  duct  of  San- 
torini  is  patulopus. 

Atypical  cases  of  carcinoma  of  the  pancreas  which  develop  after 
symptoms  of  gall-stones,  gastric  or  duodenal  disease,  as  well  as  those 
in  which  obstruction  of  the  choledochus  does  not  occur,  and  those 
exhibiting  a  palpable,  movable  tumor,  cause  extreme  difficulty  in 
diagnosis  and  it  is  at  times  impossible  to  make  a  positive  diagnosis. 

Carcinoma  in  the  body  or  tail  of  the  pancreas  can  scarcely  be 
differentiated  from  other  palpable  tumors  in  the  upper  abdomen, 
for  it  may  be  as  freely  movable  as  any  of  the  commoner  tumors,  and 
will  not  cause  obstructive  jaundice  nor  symptoms  of  pancreatic  in- 
sufficiency. Gastric  and  intestinal  symptoms  and  the  more  superficial 
position  of  the  tumor  favor  the  diagnosis  of  an  extra-pancreatic  origin, 
but  much  reliance  cannot  be  placed  on  these  points. 

Differential  Diagnosis.  Carcinoma  of  the  Common  Duct. — For 
practical   purposes    this   includes   carcinoma   of   the  papilla,   of  the 


700  TUMORS    OF   THE    PANCREAS 

ampulla  of  \'ater,  of  the  common  bile-duct  and  of  the  main  hepatic 
duct. 

Primary  carcinoma  of  the  common  bile-duct  is  very  much  less 
frequent  than  carcinoma  of  the  pancreas.  Contrary  to  what  might 
be  expected,  gall-stone  disease  does  not  appear  to  be  a  predisposing 
factor  in  cancer  of  the  bile-passages. 

In  primary  carcinoma  of  the  common  duct  the  onset  usually 
is  insidious  and  after  a  varying  period  in  which  ill-defined  epigastric 
symptoms  are  manifested,  jaundice  appears  and  deepens  gradually 
but  persistently.  So  far  the  resemblance  to  pancreatic  carcinoma 
is  striking,  but  until  the  pancreatic  ducts  are  obstructed  by  the  growth 
in  the  choledochus  there  are  no  signs  of  pancreatic  insuli&ciency. 
From  this  time  on  the  case  runs  the  same  clinical  course  as  carcinoma 
of  the  head  of  the  pancreas  and  the  two  conditions  are,  as  a  rule, 
impossible  of  differentiation,  except  on  the  grounds  that  carcinoma 
of  the  head  of  the  pancreas  is  much  commoner  than  common  duct 
cancer  and  is  associated  with  more  rapid  emaciation  and  loss  of 
strength  because  of  the  early  interference  with  pancreatic  digestion. 
Carcinoma  of  the  gall-bladder  simulates  cancer  of  the  head  of  the 
pancreas  only  when  the  growth  has  extended  to  and  occluded  the 
ampulla  of  Vater,  causing  both  obstructive  jaundice  and  pancreatic 
insuli&ciency.  When  jaundice  is  due  to  involvement  of  the  liver, 
and  not  to  obstruction  of  the  choledochus,  bile  is  not  absent  from  the 
duodenum. 

The  history  of  gall-stone  disease  or  of  prolonged  upper  abdominal 
symptoms,  the  comparatively  late  onset  of  jaundice,  the  absence  of  the 
smooth,  rounded,  gall-bladder  tumor  and  in  its  place  a  hard,  nodular 
tumor  or  no  tumor  at  all,  make  a  clinical  picture  much  different  from 
that  of  carcinoma  of  the  head  of  the  pancreas. 

Extension  of  malignant  disease  to  the  ducts  from  neighboring  organs 
is  preceded  by  symptoms  of  the  primary  disease,  and  jaundice  is  a  late 
symptom. 

Stone  in  the  Common  Duct. — The  history  of  previous  attacks, 
the  onset  of  jaundice  after  colic,  the  intermittent  character  of  the  jaun- 
dice, the  fact  that  there  is  little  or  no  loss  of  weight  and  strength  for 
a  long  time  after  the  initial  symptoms,  the  absence  of  a  gall-bladder 
tumor  and  the  presence  of  bile  in  the  duodenum  all  serve  to  differ- 
entiate gall-stones  from  pancreatic  cancer.  In  addition,  obstruction 
of  the  common  duct  by  a  stone  usually  gives  rise  to  intermittent 
fever,  while  the  temperature  is  normal  or  subnormal  in  cancer  of  the 
pancreas. 


CARCINOMA  701 

Chronic  Interstitial  Pancreatitis. — When  the  abdomen  is  opened 
and  the  pancreas  examined  directly  by  sight  and  touch  it  often  is 
impossible  to  differentiate  carcinoma  and  pancreatitis.  A  preceding 
history  of  gall-stone  disease  or  other  predisposing  factor  to  pancreatitis, 
and,  as  a  rule,  the  slower  loss  of  weight  and  strength  in  pancreatitis 
help  in  differentiation.  In  inflammatory  disease  the  gall-bladder 
usually  is  contracted,  but  even  when  it  is  distended  it  is  sometimes 
possible,  to  distinguish  it  from  the  distended  gall-bladder  which  results 
from  malignant  obstruction  by  its  friability.  In  malignant  disease  the 
gall-bladder,  unless  itself  involved  in  the  carcinomatous  process,  is 
much  more  resistant  and  sutures  inserted  in  it  are  much  less  apt  to  tear 
out  than  in  the  case  of  a  gall-bladder  which  is  the  seat  of  longstanding 
inflammatory  change. 

In  undetermined  cases  the  patient  should  be  given  the  benefit 
of  the  doubt  and  treated  as  for  pancreatitis. 

Cancer  of  the  Liver. — Absence  of  the  evidence  of  complete  obstruc- 
tion of  the  bile-ducts,  the  late  onset  of  jaundice,  enlargement  of  the 
liver,  palpable  nodules  on  the  surface  of  the  liver,  and  lack  of  symptoms 
and  signs  due  to  interference  with  pancreatic  digestion  indicate  the 
probable  diagnosis. 

Cancer  of  the  Pylorus. — Even  if  jaundice  does  occur  it  is  a  late 
symptom  due  to  extension  or  metastasis.  The  gastric  symptoms 
predominate  although  pyloric  and  pancreatic  cancer  may  occur  appar- 
ently at  the  same  time  and  the  primary  seat  of  the  tumor  be  uncertain. 

The  gastric  crises  of  tabes  may  be  distinguished  from  the  visceralgia 
which  characterizes  some  cases  of  pancreatic  carcinoma  by  attention 
to  other  signs  of  locomotor  ataxia. 

Treatment. — Medical  treatment  is  symptomatic. 

In  cases  of  doubt  abdominal  section  is  indicated  as  the  condition 
may  be  amenable  to  operative  treatment.  Confluent  enlarged  lymph- 
nodes  point  to  carcinoma  while  discrete  glandular  enlargement  usually 
indicates  pancreatitis.  In  nearly  every  case  of  carcinoma  of  the  pan- 
creas the  disease  has  progressed  too  far  to  permit  removal.  Complete 
removal  of  the  pancreas  appears  to  be  necessarily  fatak  The  case 
attributed  to  Billroth  (1884)  of  recovery  after  complete  extirpation 
of  the  pancreas,  is  rejected  by  Sauve  (1908),  who  says  it  is  cited  every- 
where but  nowhere  reported.  In  cancer  of  the  body  and  tail  a  number 
of  successful  removals  have  been  recorded.  In  19 10  Finney  collected 
six  resections  of  the  body  or  tail  of  the  pancreas  with  two  deaths  from 
the  operation,  two  survivals  for  a  few  months,  one  reported  as  "re- 
covered" but  with  no  after  history,  and  Finney's  own  patient  (cystaden- 


702  TUMORS    OF    THE    PANCREAS 

oma)  who  was  in  good  health  sixteen  months  after  operation.  In 
excisions  of  the  tail,  the  stump  may  be  closed,  and  any  fistula  may  be 
expected  to  close  under  antidiabetic  diet.  In  resections  of  the  body, 
the  head  and  tail  should  be  sutured  together,  as  in  Finney's  own  case. 

Compared  to  the  number  of  actual  cases,  successful  removal 
must  be  looked  upon  as  only  rarely  possible,  but  should  always  be 
undertaken  if  there  is  the  slightest  possible  chance  of  success.  Sauve 
quotes  Terrier's  maxim:  Dans  le  doute,  ne  t'abstiens  jamais. 

A  radical  operation  for  carcinoma  of  the  head  of  the  pancreas  involves 
also  removal  of  the  second  or  descending  portion  of  the  duodenum. 
The  operative  technique  has  been  well  systematized  by  Desjardins 
(1907)  and  by  Sauve  (1908),  the  latter  of  whom  uses  the  term 
cephalic  duodeno-pancreatectomy  to  describe  the  operation.  He 
collected  sixteen  cases  of  cephalic  pancreatectomy  of  which  the  details 
are  known,  and  refers  to  five  others  merely  mentioned  in  journals.  Of 
these  sixteen  patients,  nine  survived  the  operation  (Ruggi,  Sendler, 
Codivilla,  Biondi,  Tricomi,  Franke,  Duval,  Villareal,  Mauclaire) 
and  three  patients  were  in  good  health  a  year  later,  but  these  three  did 
not  have  cancer  (Sendler,  Biondi,  Duval).  Of  all  the  operations  col- 
lected by  Sauve  that  of  Codivilla  was  the  most  ideally  complete  :cephahc 
duodeno-pancreatectomy,  with  gastro-jejunostomy  in-Y,  and  cholecyst- 
enterostomy;  his  patient  lived  twenty-four  days,  and  succumbed  then 
to  the  preexistent  cachexia.  The  patients  of  Tricomi  and  Franke  sur- 
vived for  five  months  and  six  months,  respectively.  Cordoy,  Mauclaire, 
Villareal,  and  Moynihan  employed  duodeno-pancreatectomy;  while 
Cuneo  adopted  the  method  employed  by  Tufiier  in  a  case  of  carcinoma 
of  the  papilla  of  Vater  invading  the  pancreas.  This  consisted  in  enu- 
cleation of  the  head  of  the  pancreas  and  excision  of  the  ampulla  of 
Vater;  the  stump  of  the  pancreas  was  fixed  in  the  abdominal  wound. 
Even  in  the  technique  recommended  by  Sauve,  and  which  is  described 
in  detail  at  page  795,  the  stump  of  the  pancreas  is  fixed  in  the  abdominal 
wound.  In  the  technique  proposed  by  Desjardins  the  pancreatic 
stump  is  implanted  into  the  intestine.  Cofi'ey  (1909),  in  experimental 
work  on  dogs,  sought  a  technique  to  facilitate  such  a  step.  The  best 
way  to  do  this,  he  found,  was  to  throw  the  lumen  of  two  intestines 
into  one  by  using  a  loop,  and  thus  allow  ample  room  for  invagination 
of  the  pancreas  (page  799). 

Cholecystostomy  and  cholecystenterostomy  do  not  prolong  life 
to  any  extent  and  a  number  of  the  patients  die  as  a  result  of  the  opera- 
tion. Symptomatic  relief  usually  is  afforded  to  those  who  survive: 
the  jaundice  lessens  or  disappears,  digestion  and  appetite  improve. 


SARCOMA 


703 


and  the  patients  enjoy  an  interval  of  reasonable  comfort  which  would 
be  absent  were  operation  refused.  The  results  of  these  operations  in 
cases  of  malignant  disease  have  been  noted  at  pages  505  and  591. 
The  immediate  results  in  patients  under  the  senior  author's  care  during 
the  past  eight  years  are  indicated  in  the  accompanying  table: 

Operations  tor  Carcinoma  of  Pancreas  (iqi  2-1920) 
(Lankenau  Hospital) 


Operation 

Associa 

ted  lesions 

Cases 

Deaths 

I 
3 
I 
5 

0 

Cholecystectomy 

Cholecystectomy  and  choledochostomy 

Calculus 

Calculus 

3 

I 
I 

10 

5 

Sarcoma  of  the  Pancreas. — Kakels  in  1902  collected  twenty- 
one  cases.  Primary  sarcoma  is  very  rare  and  while  secondary  involve- 
ment occurs  more  frequently  it  is  still  an  uncommon  condition.  In 
1909  Ravenna  recorded  from  the  literature  twenty  cases  of  primary 
sarcoma  and  reported  two  original  cases.  Villard  and  Stefani  have 
since  recorded  an  operation  in  which  marsupialization  was  done  for 
polycystic  sarcoma  of  the  pancreas;  death  occurred  eight  days  later. 

Primary  sarcoma  is  of  the  small  round-celled  variety,  or  lympho- 
sarcoma. Secondary  sarcoma  is  also  usually  lymphosarcoma  and 
arises  from  the  mediastinal  or  abdominal  lymph-nodes  or  from  the 
duodenum.  A  number  of  cases  of  melanotic  sarcoma  are  reported  and 
usually  have  resulted  from  metastasis  from  the  eye. 

Segre  (1888)  reported  two  primary  sarcomas  occurring  in  11,492 
autopsies.  Hale  White  (1897)  found  one  in  6708  autopsies.  In  Fin- 
ney's report  (1910)  of  seventeen  cases  of  resection  of  the  pancreas, 
sarcoma  occurred  four  times,  two  of  the  patients  recovering.  One  of 
these  died  of  recurrence  within  a  few  months. 

Diagnosis  is  scarcely  possible  before  operation. 

If  the  tumor  is  in  the  body  or  tail  successful  removal  is  possible. 
If  the  growth  is  in  the  head  of  the  gland  cephaHc  duodeno-pancreatec- 
tomy  may  be  done  but  usually  patients  are  seen  too  late  for  radical 
treatment  to  be  successful. 

Adenoma  is  of  pathological  rather  than  surgical  interest  (Cecil, 
1911).     The  diagnosis  is  made  by  microscopic  examination  and  there 


704  TUMORS    OF   THE    PAXCREAS 

are  no  characteristic  symptoms  or  physical  signs.     A  certain  number  of 
successful  removals  have  been  reported. 

Cysts  or  the  Pancreas 

The  percentage  incidence  of  pancreatic  cysts  is  difficult  to  deter- 
mine because  the  majority  of  collected  cases  are  reports  of  operation, 
most  often  only  incision  and  drainage,  where  the  true  origin  and  con- 
nections of  the  tumor  could  not  be  ascertained  with  any  degree  of 
accuracy.  For  this  reason  it  is  probable  that  many  cases  are  classed 
as  pancreatic  although  the  cysts  have  arisen  independently  of  the 
pancreas. 

Classification. — The  simplest  and  most  convenient  classifica- 
tion is  into  true  cysts  and  false  or  pseudocysts.  The  former  include 
those  due  to  retention  of  pancreatic  secretion,  cystic  new  growths, 
hydatid  cysts  and  congenital  cystic  disease.  Pseudocysts  arise  in  close 
association  with  the  pancreas  and  involve  it  secondarily.  These 
cysts  usually  are  formed  by  effusions  the  result  of  abdominal  injuries. 
Some  authors  classify  with  these  extra-pancreatic  pseudocysts  those 
which  arise  in  the  pancreas  as  a  result  of  hemorrhage  from  injury  or 
acute  pancreatitis.  As  these  are  practically  indistinguishable  from 
true  retention  cj^sts  such  a  classification  is  not  rational  from  a  clinical 
standpoint. 

Etiology.  Age. — The  years  between  twenty  and  forty  furnish 
most  of  the  cases.  Railton  (1896)  reported  a  pancreatic  cyst  in  a 
six  months  old  child;  Shattuck.  (cited  by  Richardson,  1882),  one  in  a 
child  thirteen  months  old;  Connelly  (191 1)  and  Richardson  (1895), 
each  one  in  a  child  fourteen  months  old;  while  Stieda  (1893)  reported  a 
case  in  a  man  seventy-six  years  old. 

5ea'.^Robson  and  Cammidge  (1907)  saj-  that  true  cysts  are  more 
common  in  women  and  pseudocysts  more  common  in  men,  presumably 
because  the  latter  are  more  exposed  to  injury.  Korte's  statistics 
(1898)  show  almost  equal  incidence  in  men  and  women. 

Traumatism. — Experimental  evidence  shows  that  injury  to  the 
pancreas  causing  hematoma  results  in  cyst  formation. 

Pancreatic  Cyst   Following  Trauma;  E.xternal  Pancreatic  Fistula 
Spontaneously  Developed;  Operation;   Recovery 

A  woman  27  years  of  age  came  under  the  care  of  the  senior  author  in  the  Lankenau 
Hospital.  Her  cliief  complaint  was  a  fistula  in  the  left  hjpochondriac  region.  Five  years 
previous  to  her  admission  she  had  suflFered  from  dyspepsia  for  a  period  of  6  months,  and 


CYSTS  70s 

since  that  illness  a  dull  pain  had  persisted  to  the  left  of  the  epigastrium.  Three  years  ago 
she  fell  and  struck  her  lower  left  chest;  shortly  afterward  she  noticed  a  lump  in  the  region 
where  the  pain  had  previously  been  felt.  This  lump  had  grown  slowly  for  the  past  two 
years,  causing  a  sensation  of  weight  and  fulness  in  the  upper  left  abdomen.  Two  days  ago 
this  lump  ruptured  externally,  and  large  quantities  of  white  cloudy  fluid  were  discharged, 
with  some  relief  to  the  discomfort. 

The  fistula,  which  was  3  cm.  below  the  left  costal  margin,  e.xuded  clear  mucus  which  was 
very  irritating  to  the  skin;  and  the  skin  was  e.xcoriated  over  an  area  5  cm.  in  diameter. 
Examination  of  the  fluid  showed  that  it  partly  digested  the  white  of  an  egg. 

At  operation  the  fistula  was  traced  through  the  gastro-hepatic  omentum  to  the  pan- 
creas, where  the  tract  was  ligated  and  the  fistulous  tract  e.xcised.  Recovery 
was  uneventful. 

In  thirty-three  (28  per  cent.)  of  the  117  cases  collected  by  Korte 
there  was  a  history  of  some  abdominal  injury,  these  injuries  usually 
being  direct  blows  of  varying  degrees  of  violence;  although  falls,  com- 
pression of  the  abdomen,  etc.,  have  also  preceded  and  apparently 
caused  a  certain  number  of  pancreatic  cysts. 

Previous  Pathological  Conditions. — All  conditions  likely  to  be  asso- 
ciated with  chronic  interstitial  pancreatitis  have  been  described  in 
connection  with  pancreatic  cysts.  Calculi,  tumors,  chronic  infection 
of  the  duodenum  and  bile-passages,  duodenal  and  gastric  ulcer  and 
pancreatic  lymphangeitis  have  been  mentioned  as  pathological  lesions 
accompanying  pancreatic  cysts.  Whether  they  cause  both  the  cyst 
and  the  pancreatitis  or  whether  the  cysts  result  from  the  pancreatitis 
is  hard  to  determine.  Robson  and  Cammidge  favor  the  latter  supposi- 
tion and  think  that  when  cyst,  calculus  and  chronic  pancreatitis  occur 
together  the  two  former  have  a  common  cause  in  the  latter. 

Acute  hemorrhagic  pancreatitis  has  frequently  resulted  in  cyst 
formation. 

Pathology.  Retention  Cysts. — It  is  doubtful  if  simple  obstruc- 
tion of  the  pancreatic  duct  or  one  of  its  branches  leads  to  the  for- 
mation of  a  cyst  or  cysts.  Those  observers  who  think  that  it  does 
believe  that  there  is  a  change  in  the  character  of  the  pancreatic  juice, 
which  as  a  result  of  stagnation  becomes  less  easily  absorbed.  Subse- 
quently this  causes  disintegration  of  the  glandular  tissue  with  the 
formation  of  a  cavity  into  which  secretion  and  exudate  are  poured  out. 
Failure  to  cause  cyst  formation  in  certain  cases  is  ascribed  to  non- 
closure of  the  duct  of  Santorini.  After  causing  only  slight  dilatation  of 
the  duct  Senn  (1885)  suggested  that  complete  obstruction  would  lead 
to  atrophy,  but  that  intermittent  obstruction,  as  by  a  calculus,  would 
cause  cyst  formation  in  the  same  manner  that  a  stone  in  the  ureter 
causes  hydronephrosis.  While  such  theories  may  furnish  a  partial 
explanation  of  the  mode  of  origin  of  cysts,  there  are  other  unknown 


7o6  TUMORS   OF  THE  PANCREAS 

factors,  as  is  shown  by  the  fact  that  the  same  etiological  factors  blamed 
for  the  formation  of  cysts  are  brought  forward  as  direct  causes  of  chronic 
interstitial  pancreatitis.  We  have  no  knowledge  as  to  why  the  same 
conditions  at  one  time  cause  cyst  formation  and  at  another  do  not. 
There  is  always  a  certain  amount  of  pancreatitis  in  association  with 
cysts  of  the  pancreas,  and  Robson  and  Cammidge  express  the  opinion 
that  the  cyst  is  the  direct  result  of  the  compression  of  the  duct  by 
contracting  bands  of  scar  tissue.  This  removes  the  difficulty  only  a 
step  farther,  as  it  does  not  explain  why  a  cyst  occurs  in  one  case  of 
pancreatitis  and  not  in  another. 

Thiroloix  (1897)  altered  the  contents  of  the  ducts  before  Hgating 
both,  by  injecting  soot  and  carbolized  vaseline,  and  caused  the  for- 
mation of  a  cyst  with,  in  addition,  very  advanced  chronic  pancreatitis. 
The  determining  factor  of  cyst  formation  in  this  case  is  supposed 
to  have  been  the  alteration  of  the  pancreatic  juice  by  the  foreign 
matter  injected,  which  interfered  with  absorption. 

It  is  not  yet  clear  that  the  chronic  pancreatitis  may  not  be  the 
result  of  extension  of  the  chronic  inflammation  always  found  around 
the  wall  of  a  cyst. 

Pancreatic  calculi,  gall-stones,  duodenal  ulcer,  tumors  and 
lymphangeitis  have  all  been  found  in  association  with  retention  cysts 
but  their  connection  therewith  is  not  understood.  If  they  obstruct  the 
duct  this  may  cause  a  rapid  increase  in  size  of  a  preformed  cyst,  but 
there  is  no  definite  reason  for  saying  that  they  are  causative  factors. 

All  sizes  and  conditions  of  cysts  occur;  uni-  and  multi-locular 
cysts,  single  and  multiple,  large  and  small,  occur  in  all  sorts  of  com- 
binations and  the  etiology  of  the  various  combinations  is  uncertain. 

Virchow  (1S87)  described  a  multiple  dilatation  of  the  duct  of 
Wirsung,  caused  by  obstruction  from  a  tumor  of  the  duodenum, 
which  he  termed  "ranula  pancreatica."  Multiple  small  cysts,  the 
result  of  obstruction  of  the  smaller  ducts,  were  named  "acne  pancre- 
atica" by  Klebs  (1869).  These  two  forms  are  uncommon  and  of  no 
significance  from  the  standpoint  of  diagnosis  and  surgical  treatment. 

Small  cysts  are  recognized  either  at  autopsy  or  in  the  course  of 
upper  abdominal  operations  for  other  conditions. 

Large  single  or  multi-locular  cysts  offer  the  best  opportunity 
for  diagnosis  and  treatment.  They  are  said  to  be  associated  with 
obstruction  of  the  large  branches  of  the  main  duct  and  vary  in  size 
up  to  enormous  proportions,  cysts  containing  fifteen  Hters  and  more 
having  been  reported. 

The  walls  of  a  retention  cyst  consist  of  dense  fibrous  tissue  of 


CYSTS  707 

varying  thickness.  The  inner  surface  may  be  lined  more  or  less 
completely  by  a  single  layer  of  cylindrical  epithehum,  indicating 
the  origin  of  the  cyst  from  a  dilated  duct.  The  absence  of  this  epithe- 
lial layer  is  no  proof  that  it  is  not  a  true  retention  cyst  as  the  action 
of  the  cyst  contents  may  destroy  the  epithelium.  Portions  of  pancre- 
atic tissue  may  be  found  included  in  the  walls  of  these  cysts,  indicating 
a  true  pancreatic  origin.  Continued  increase  in  size  of  a  cyst  causes 
more  or  less  destruction  of  pancreatic  tissue  even  in  those  cases  where 
the  growth  is  mostly  away  from  the  pancreas.  The  outer  surface  of 
the  larger  cysts  is  traversed  by  greatly  distended  blood-vessels. 

Proliferation  Cysts. — These  cysts  are  formed  by  prohferation 
of  the  duct  epithelium  and  accumulation  of  fluid.  They  are  of  two 
kinds,  benign  and  malignant.  Benign  cysts  have  much  the  same 
characteristics  as  multi-locular  ovarian  cystadenomas.  They  are 
multi-locular,  with  small  cysts  in  the  walls  of  the  larger  ones,  and 
frequently  there  are  papilhferous  growths  on  the  inner  surface.  As 
a  rule  such  a  cyst  is  lined  with  columnar  epithelium,  but  this  may  have 
been  destroyed  by  the  cyst  contents. 

A  few  cases  of  malignant  cyst  have  been  reported.  They  occur 
as  epithehomas  without  regular  form  and  are  usually  made  up  of 
numbers  of  small  cysts. 

Remnants  of  the  Wolffian  body  are  said  to  give  rise  to  tumors 
resembUng  proliferation  cysts  of  the  pancreas.  All  of  these  growths 
are  rare. 

Traumatic  Cysts. — Differentiation  of  these  cysts  depends  more 
upon  the  etiological  factor  of  injury  than  on  any  special  pathological 
characteristics.  Trauma  may  be  a  factor  in  causing  either  true  or 
false  cysts.  The  presence  of  blood  in  the  cyst  contents  is  not 
demonstrative  of  traumatism,  since  hemorrhage  may  occur  as  the 
result  of  rupture  of  vessels  in  the  wall  of  a  cyst  already  formed;  on 
the  other  hand,  a  cyst  undoubtedly  due  to  injury  may  contain  clear 
watery  fluid  with  no  macroscopic  evidence  of  blood.  Occasionally 
a  cyst  has  old  clots  adherent  to  the  wall,  the  result  of  previous 
hemorrhage. 

The  fact  that  traumatism  will  give  rise  to  pancreatic  cysts  receives 
ample  confirmation  from  both  experimental  and  clinical  observations. 
Lazarus  (1904)  produced  a  cyst  by  crushing  the  pancreas  of  a  dog, 
forming  a  hematoma,  which  later  became  an  encapsulated  cyst  contain- 
ing 100  c.c.  of  watery  fluid. 

Traumatic  cysts  are  very  frequently  situated  in  the  lesser  peritoneal 
cavity,  having  little  or  no  direct  association  with  the  pancreas. 


7o8  TUMORS    OF    THE    PANCREAS 

Hydatid  Cysts. — Hydatid  cysts  of  the  pancreas  are  extremely 
rare  and  present  practically  no  symptoms  or  physical  signs  by  which 
they  can  be  recognized  definitely  as  hj^datid  cysts  of  the  pancreas 
in  contradistinction  to  other  cysts  of  the  pancreas  or  hydatid  cysts 
of  neighboring  viscera. 

Congenital  cystic  disease  is  rare  and  has  little  or  no  clinical  sig- 
nificance; it  is  evidenced  by  multiple  small  cysts  as  in  congenital 
cystic  disease  of  other  organs.  The  cases  of  cyst  reported  in  children 
from  six  to  fourteen  months  of  age  probably  are  not  cases  of  congenital 
cystic  disease,  as  they  had  all  the  characteristics  of  retention  cysts. 

Contents. — The  appearance  and  character  of  the  fluid  contents 
of  pancreatic  cysts  and  pseudocysts  vary  considerably. 

The  contents  may  be  almost  any  color,  but  usually  are  light  brown, 
although  in  many  reported  cases  the  cysts  have  contained  clear  watery 
fluid.  The  presence  of  blood  in  varying  quantities  influences  the  color, 
according  to  the  length  of  time  that  has  elapsed  since  the  blood  escaped. 
The  presence  of  enzymes  also  causes  alteration  in  the  color  and  may 
be  responsible  for  the  loss  of  the  products  of  hemorrhage  in  the  cyst 
contents.  Enzymes  may  also  be  responsible  for  the  presence  of  blood 
in  the  fluid  by  causing  erosion  of  the  vessels  in  the  wall  of  the  cyst. 

The  character  of  the  contents  varies  from  watery  fluid  to  a  thick 
syrupy  or  colloid  substance  too  thick  to  run  freely  through  an  aspirating 
trochar.     It  is  purulent  if  suppuration  has  occurred. 

Macroscopic  examination  therefore  oflfers  very  slight  assistance 
in  determining  the  origin  of  such  a  cyst.  Opinions  dift'er  as  to  the  value 
to  be  attached  to  the  chemical  analysis  and  microscopic  examination. 

Chemical  Analysis. — The  presence  in  the  cyst  contents  of  various 
ferments,  rich  in  the  usual  digestive  powers  of  the  pancreas,  is  strong 
presumptive  evidence  that  the  cyst  is  of  pancreatic  origin.  This  is 
undoubtedly  true  if  the  fluid  digests  albumen,  starch  and  fat.  When 
all  three  ferments  are  present  it  is  practically  certain  that  the  cyst 
communicates  directly  with  the  pancreas,  but  the  presence  of  only 
one  (unless  it  is  the  fatsplitting  ferment)  is  not  diagnostic.  Many 
cysts  of  undoubted  pancreatic  origin  do  not  contain  all  three  ferments 
and  each  one  of  the  three  has  been  demonstrated  in  cysts  of  extra- 
pancreatic  origin.  The  absence  of  pancreatic  ferments  in  a  true  cyst 
is  due  to  the  fact  that  chronic  disease  of  the  pancreas  interferes  with 
its  secretory  function.  Their  presence  in  pseudocysts  is  due  to  com- 
munication with  the  parenchyma  of  the  pancreas. 

The  other  characteristics  of  pancreatic  cyst  fluids  are:  an  alkaline 
reaction;  a  specific  gravity  from  loio  to  1020,  although  it  m.ay  be 


CYSTS  709 

much  higher;  the  constant  presence  of  albumen;  the  frequent  presence 
of  cholesterin;  the  occasional  presence  of  mucin;  and  rarely  the  presence 
of  traces  of  urea. 

Microscopic  cxaminalion  reveals  red  and  white  blood  cells,  epithe- 
lium, fat  globules,  necrotic  tissue  and  frequently  cholesterin  crystals. 

Symptoms  and  Physical  Signs. — There  are  many  cases  in  which 
the  only  recorded  symptom  is  the  appearance  and  gradual  growth 
of  an  abdominal  tumor,  but  these  cases  are  exxeptional.  The  presence 
of  the  tumor  and  the  associated  inflammatory  and  pressure  changes 
usually  result  in  marked  digestive  and  constitutional  changes.  Pain 
also  is  a  fairly  constant  symptom. 

Pain. — This  varies  in  severity  from  a  feeling  of  discomfort  or 
distention  to  attacks  of  severe  lancinating  pain  common  to  the  serious 
abdominal  crises.  Pain  may  be  continuous,  intermittent  or  con- 
tinuous with  acute  exacerbations.  At  times  the  pain  is  severe  enough 
to  resemble  acute  intestinal  obstruction,  and  often  is  accompanied 
by  vomiting  and  collapse,  which  still  further  confuse  the  diagnosis. 
Very  little  dependence  can  be  placed  on  the  localization  of  the  pain. 
Usually  it  is  most  severe  in  the  upper  abdomen,  and  is  deeply  seated. 
From  this  position  it  may  radiate  into  either  hypochondrium,  to  the 
back  or  the  lower  abdomen. 

Pain  may  be  present  before  there  is  any  definite  tumor  or  its 
appearance  may  be  delayed  until  the  cyst  has  reached  a  large  size. 

The  relation  between  eating  and  the  occurrence  of  pain  is  usually 
indefinite,  but  at  times  it  occurs  only  after  eating  and  may  be  associated 
with  vomiting. 

Vomiting  depends  on  two  factors,  the  severity  of  the  pain  and 
the  interference  with  gastric  function.  It  is  almost  always  a  con- 
comitant symptom  when  pain  is  severe,  and  it  has  a  close  relationship 
to  the  occurrence  of  exacerbation.  Vomiting  is  also  a  constant  feature 
in  those  cases  where  the  growth  of  the  cyst  directly  compresses  the 
stomach.  It  may  be  the  delayed  vomiting  of  obstruction  of  the 
pylorus,  or  reflex  vomiting  from  gastric  irritability. 

Pressure  Symptoms. — The  grouping  of  these  symptoms  depends 
on  the  direction  of  growth  of  the  cyst.  Pressure  on  the  stomach 
causes  indigestion,  flatulence,  discomfort  after  eating,  anorexia  and 
finally  vomiting. 

Jaundice  may  be  due  to  direct  pressure  on  the  common  bile-duct 
or  to  associated  pancreatitis  or  gall-stones.  Constipation  results 
from  pressure  on  the  colon  and  in  a  few  recorded  cases  this  has  gone 
on  to  actual  obstruction. 


7IO  TUMORS    OF   THE   PANCREAS 

INIore  remote  results  of  pressure  are  ascites  from  obstruction  of 
the  portal  vein,  edema  of  the  lower  limbs  from  obstruction  to  the 
inferior  vena  cava,  and  hydronephrosis  from  pressure  on  the  ureter. 

Functional  Disturbances. — The  presence  or  absence  of  functional 
disturbances  depends  on  the  original  cause  of  the  cyst  formation  and 
on  the  degree  of  destruction  of  pancreatic  parenchyma.  If  the  cyst 
is  caused  by  or  associated  with  chronic  pancreatitis  the  presence  or 
absence  of  the  signs  of  pancreatic  indigestion  depends  on  the  extent 
of  involvement.  These  signs,  steatorrhea,  azotorrhea,  bulky  pale 
stools,  etc.,  are  evidence  of  pancreatitis  and  not  of  pancreatic  cyst, 
but  their  presence  in  conjunction  with  an  upper  abdominal  tumor 
having  the  physical  characters  of  a  pancreatic  cyst  would  be  strongly 
corroborative  evidence.     Occasionally  glycosuria  is  present. 

The  absence  of  signs  indicating  pancreatic  insufficiency  does  not 
rule  out  a  diagnosis  of  cyst  of  the  pancreas,  but  simply  means  that 
there  has  not  been  suflScient  destruction  of  glandular  parenchyma 
to  interfere  with  its  function. 

Loss  of  weight  and  strength  is  nearly  always  an  accompaniment 
of  large  cysts  and  may  be  well  marked  even  in  those  of  moderate 
size.  It  results  from  various  causes,  notably  from  interference  with 
pancreatic  digestion,  vomiting  and  gastro-intestinal  disturbances 
and  possibly  from  obscure  metabolic  changes. 

Physical  Signs. — ;The  ph3'sical  signs  depend  on  the  presence, 
direction  and  rapidity  of  growth  of  a  cystic  tumor  originating  in 
the  upper  abdomen  between  the  ensiform  and  umbilicus.  In  the 
majority  of  instances  the  tumor  occupies  the  middle  line  and  projects 
to  the  left  side  more  often  than  the  right.  Unless  too  small  to  reach 
the  surface,  the  recognition  of  a  rounded,  smooth  cystic  tumor  is 
easily  demonstrated  by  abdominal  palpation.  The  physical  signs 
vary  with  the  direction  of  growth  from  the  point  of  origin. 

Korte  (1898)  made  three  classes  of  pancreatic  cysts  accord ing  to  tfie 
direction  of  growth.  In  addition  there  are  cases  that  do  not  lit  into 
any  of  these  groups.  The  direction  of  growth  is  influenced  by  the 
origin  of  the  cyst  in  relation  to  the  reflections  of  peritoneum  from 
the  pancreas.  Dilatation  of  the  stomach  and  colon  with  air  shows 
the  relation  of  a  cyst  to  these  viscera.  The  degree  of  dilatation 
influences  the  amount  of  contact  between  the  tumor  and  the  abdominal 
wall. 

I .  The  first  of  Korte 's  groups  comprises  those  tumors  that  grow 
forward  between  the  transverse  colon  and  the  stomach,  displacing  the 
latter  upward  and  the  former  downward  (Fig.   167).     The  amount 


CYSTS 


711 


of  displacement  depends  on  the  size  of  the  tumor  and  the  amount 
of  air  in  the  viscera.  Cysts  following  this  line  of  growth  arise  from 
the  anterior  surface  of  the  head  or  body  of  the  pancreas  or  are  pseudo- 
cysts formed  in  the  lesser  peritoneal  cavity. 

2.  The  second  group  includes  growths  from  the  upper  part  of  the 
anterior  surface  of  the  head  or  body  of  the  pancreas  which  grow  forward 
below  the  liver  and  above  the  lesser  curvature  of  the  stomach,  dis- 
placing the  latter  downward  (Fig.  168).  This  direction  of  growth  is 
prone  to  occur  in  those  patients  subject  to  gastroptosis. 


Fig.  167. — Cyst  of  Pancreas  Presenting 
Beneath  the  Gastro-colic  Omentum. 


Fig.  168. — Cyst  of  Pancreas  Presenting 
Beneath  the  Gastro-hepatic  Omentum. 


3.  The  third  group  comprises  cysts  from  the  tail  of  the  pancreas. 
This  lies  on  the  left  of  the  duodeno-jejunal  junction  and  cysts  develop- 
ing here  grow  into  the  transverse  mesocolon  and  displace  the  colon 
in  one  of  three  ways,  upward,  downward  or  directly  forward.  If  the 
colon  is  displaced  downward  the  tumor  grows  toward  the  left  hypoch- 
drium  simulating  a  splenic  growth.  A  cyst  that  comes  out  below 
the  colon  or   pushes  it  directly  forward,   grows  toward  the  midline 


712 


TUMORS    OF    THE    PANCREAS 


forming  a  tumor  of  the  middle  abdomen.     Its  relation  to  the  colon 

is  readily  determined  by  distending  the  latter  (Fig.  169). 

The  line  of  growth  toward  the  left  hypochondruim  may  also  be  taken 

by    cysts    arising   from    the    body  or  tail  of  the  pancreas  above  the 

reflection  of  the  transverse  mesocolon. 

Retroperitoneal  growth  into  either 
flank  may  occur  in  cysts  arising  from 
the  posterior  surface  of  the  pancreas. 
These  cysts  resemble  tumors  of  the 
kidney  or  suprarenal. 

Growth  into  the  layers  of  the 
mesentery  resembling  a  mesenteric 
cyst ;  growth  f oward  from  the  head  of 
the  pancreas  below  the  reflexion  of  the 
transverse  mesocolon  below  the  hepatic 
flexure  of  the  colon,  resembling  a  tumor 
of  the  cecum,  ascending  colon  or  right 
kidney;  and  growth  through  the  for- 
amen of  Winslow  into  the  general 
peritoneal  cavity  have  all  been  re- 
ported, but  the  majority  of  cases  fall 
into  one  or  another  of  Korte's  three 
main  groups. 

Mobility  of  an  upper  abdominal 
tumor  does  not  exclude  a  pancreatic 
origin,  and  some  cysts  particularly  those 
that  arise  from  the  tail  of  the  pancreas, 
often  are  freely  movable. 

Pancreatic      tumors      as      a      rule 

transmit    the    pulsation    of    the    aorta. 

when    the    patient    is   in    the   knee-chest 


Fig.    169. — Cyst  of  Pancreas  Growing 
into  the  Transverse  Mesocolon. 


This    transmission    ceases 
posture. 

Disappearance  of  a  cyst  may  be  caused  by  rupture  the  result  of  an 
injury  or  exploratory  puncture  for  diagnosis.  Several  cases  have  been 
reported  in  which  the  cyst  disappeared  as  the  result  of  discharging  its 
contents  into  the  bowel  by  way  of  the  pancreatic  ducts,  or  by  means  of  a 
fistulous  opening.  This  disappearance  is  followed  by  profuse  diarrhea 
of  material  resembling  cyst  contents  or  saliva.     These  cysts  may  refill. 

Diagnosis. — From  the  above  description  it  is  evident  that  there  are 
no  pathognomonic  symptoms  or  physical  signs  of  pancreatic  cyst. 
A  history  of  epigastric  injury  is  often  an  aid  in  diagnosis.     Even  at 


CYSTS  713 

operation  it  is  impossible  to  differentiate  true  from  false  cysts  as  their 
appearance  and  growth  are  so  similar. 

Diagnosis  depends  largely  on  physical  signs  and  these  may  resemble 
those  of  growths  of  the  liver,  kidney,  suprarenal,  spleen,  mesentery  or 
ovary. 

As  a  rule,  the  history,  the  relation  existing  between  the  stomach 
and  colon,  possibly  the  accompanying  symptoms  and  signs  of  pancreatic 
insufficiency,  make  the  diagnosis  fairly  certain  in  the  majority  of  cases; 
but  in  those  exhibiting  eccentric  forms  of  growth,  particularly  if  un- 
accompanied by  any  symptoms  referable  to  the  pancreas,  the  diagnosis 
always  is  more  or  less  uncertain. 

Differential  Diagnosis.  Mesenteric  and  Omental  Cysts. — As  cysts 
of  the  pancreas  may  occupy  either  of  these  positions  and  are  also  at 
times  freely  movable,  it  is  obviously  impossible  to  differentiate  certain 
cases. 

Kidney  and  Suprarenal  Cysts. — The  resemblance  of  these  growths 
to  retroperitoneal  pancreatic  cysts  is  sometimes  very  close;  and  if 
urinary  findings,  ureteral  catheterization,  renal  symptoms.  X-rays 
and  examination  of  the  feces  give  no  clue  the  diagnosis  must  be  doubtful. 
Tympany  behind  the  axillary  hne  should  indicate  a  pancreatic  rather 
than  a  renal  growth. 

Cysts  of  the  Liver. — Almost  without  exception  these  are  echino- 
coccus  cysts,  but  they  may  closely  resemble  in  physical  signs  pancreatic 
cysts  growing  forward  between  the  liver  and  stomach.  Inflation 
of  the  stomach  might  aid  in  diagnosis  as  it  is  much  more  likely 
to  obscure  a  pancreatic  than  a  liver  tumor.  Obtaining  fluid  by 
puncture  should  ensure  a  correct  diagnosis,  but  this  is  attended 
with  considerable  danger.  Exploratory  operation  is  much  safer  and 
more  certain. 

Ovarian  Cysts. — It  should  be  the  rarest  possible  occurrence  to 
confuse  ovarian  and  pancreatic  cysts  after  careful  bimanual  examination 
under  anesthesia  if  necessary.  The  presence  of  a  normal  uterus, 
tubes  and  ovaries  in  one,  and  in  the  other  the  recognition  of  a  pedicle, 
with  possible  displacement  of  the  uterus  by  traction  or  pressure  and 
the  difference  in  history  make  confusion  of  the  two  conditions  very 
unlikely. 

Enlarged  Gall-bladder. — Close  contact  with  the  abdominal  wall, 
respiratory  movement  if  non-adherent,  dullness  continuous  with  the 
Uver  dullness,  direction  of  growth,  and  the  history  serve  to  differentiate 
a  distended  gall-bladder  from  a  cyst  of  the  head  of  the  pancreas  even 
if  the  latter  is  accompanied  by  jaundice. 


714  TUMORS    OF   THE    PANCREAS 

Cysts  of  the  Spleen. — The  history,  direction  of  growth,  physical 
signs,  particularly  the  relation  to  the  stomach,  colon,  left  rib  margin 
and  area  of  normal  splenic  dullness  serve  to  make  confusion  of  these 
two  very  unlikely. 

Prognosis. — Pancreatic  cysts  may  persist  for  years  without  causing 
any  symptoms  except  enlargement  of  the  abdomen.  These  cases, 
however,  are  exceptional. 

As  a  rule  the  course  is  progressive,  symptoms  becoming  more 
pronounced  with  increase  in  the  size  of  the  tumor.  Pressure  symp- 
toms become  marked,  interference  with  pancreatic  function  causes 
loss  of  weight  and  strength,  and  later  probably  diabetes. 

Spontaneous  or  traumatic  rupture  may  occur  at  any  time  and 
cause  death  by  shock  or  peritonitis.  Suppuration  is  not  very  in- 
frequent. W.  W.  Ashhurst  (1894)  successfully  evacuated  two  litres 
of  pus  by  pancreatotomy. 

Sudden  enlargement  accompanied  by  sj-mptoms  of  shock  indi- 
cates hemorrhage  into  the  cyst.  Of  160  operations  for  pancreatic 
cyst  mentioned  by  Robson  and  Cammidge,  recovery  ensued  in  140  cases, 
though  eight  of  these  patients  died  within  a  few  weeks  or  months. 
Of  thirteen  patients  under  their  own  care  eleven  recovered  after 
operation.  Among  eleven  operations  for  pancreatic  cyst  by  the  senior 
author,  there  was  one  death,  a  mortality  of  9  per  cent.  Four  other 
patients  have  been  under  his  care,  in  whom  the  diagnosis  of  pancreatic 
cyst  was  not  confirmed  by  operation  or  autopsy:  two  of  these  patients 
went  home  somewhat  improved  in  health,  and  two  died  before  opera- 
tion was  permitted. 

Treatment. — Medical  treatment  has  no  effect  in  staying  the 
progress  of  the  disease.  Aspiration  is  contraindicated  because  of 
the  danger  of  peritonitis  or  perforation  of  one  of  the  large  vessels 
in  the  wall  of  the  cyst. 

Complete  extirpation  is  only  occasionally  possible,  usually  in  those 
cases  where  the  cyst  arises  from  the  tail  of  the  pancreas  or  where  it 
grows  forward  between  the  layers  of  the  mesocolon.  Excision  is 
more  difficult  and  has  a  higher  mortaHty  than  incision  and  drainage 
and  is  nearly  always  impossible  because  of  adhesions  (Richardson). 
It  was  successful  in  the  case  of  the  patient  whose  history  is  detailed 
below  (Fig.  170). 

Incision  and  drainage  (marsupialization)  is  the  most  suitable 
operation  in  the  majority  of  cases.  The  incision  is  made  over  the 
most  superficial  portion  of  the  growth  and  a  rubber  tube  inserted 
into  the  cyst  cavity  after  evacuation  of  the  contents.     The  tube  is 


CYSTS 


715 


held  in  place  by  catgut  sutures  and  leakage  guarded  against  by  a 
purse-string  catgut  suture  tied  after  inverting  the  drainage  wound 
and  tube. 

Occasionally  drainage  through  the  loin  is  easier  than  through 
the  abdomen. 

The  cyst  wall  should  be  fastened  to  the  abdominal  wall  but  not 
to  the  skin. 


(•: 


Fig.  170. — Cyst  of  Pancreas  Removed  Entire  with  Pedicle  and  Some  Adjoining  Healthy 
Pancreatic  Tissue.     From  a  Patient  in  the  Lankenau  Hospital. 


The  presence  of  pancreatic  juice  in  the  drainage  fluid  indicates 
a  direct  connection  between  the  pancreas  and  the  cyst  cavity.  Care 
must  be  taken  to  avoid  excoriation  of  the  skin  by  the  pancreatic  juice 
in  the  discharge.  Ointments  with  a  mineral  rather  than  an  animal 
base  are  recommended  since  the  latter  is  digested  by  the  discharge. 
As  a  rule  granulation  tissue  gradually  obliterates  the  cavity  and  it 
closes  completely,  but  occasionally  a  small  fistula  may  persist  for 
years.  Antidiabetic  diet,  as  recommended  by  Wohlgemuth,  hastens 
the  closure  of  the  fistula  (page  658). 


7l6  TUMORS    OF    THE    PANCREAS 

Cyst  of  Pancreas;  Excision.    Recovery 

J.  M.,  aged  17  years.     Admitted  to  German  Hospital  Dec.  6,  191 2. 

Chief  Complaint. — Pain,  sharp  and  constant,  in  epigastrium;  anorexia, 
constipation. 

Previous  Medical  History. — Negative. 

Family  History. — Mother  and  father  living  and  well.  Four  brothers  and  five 
sisters  living  and  well.     Two  brothers  died  in  infancy. 

Social  History. — Eats  and  sleeps  poorly.  Bowels  irregular.  Denies  venereal 
infection.     Does  not  smoke  or  drink. 

Present  Illness. — For  past  seven  years  has  had  a  gnawing,  constant  pain  in 
stomach  just  to  left  of  midline,  4.5  centimetres  below  the  ensiform  cartilage,  and 
radiating  to  the  back.  It  was  made  worse  by  eating — the  greatest  pain  coming 
on  one-half  to  one  hour  after  eating  his  meals.  One  year  ago  the  pain  became 
more  severe  and  he  is  now  unable  to  work.  He  cannot  sleep  or  eat  anything  but 
soft  and  liquid  diet.  November  16,  1910,  he  was  operated  on  in  another  hospital 
for  acute  perforative  appendicitis;  he  made  due  recovery,  but  his  stomach  pain 
persisted  in  spite  of  it.  He  has  never  vomited  food  or  blood.  Never  has  passed 
blood  by  his  bowels,  but  has  been  constipated.  His  pain  is  present  always,  feels 
as  if  he  had  a  boil  on  the  coating  of  his  stomach.  He  has  no  distention,  no  rigidity 
and  peristalsis  is  fair. 

Physical  Examination. — .\nemic  Italian  boy  in  great  pain.  Eyes  and  ears 
negative.  Lips  pallid.  Tongue,  clear,  fissured.  Teeth,  good.  Chest,  fair 
development  and  expansion.  Heart  and  lungs,  surgically  negative,  .\bdomen. 
muscular,  seems  wasted.  No  distention  or  rigidity.  Peristalsis  good.  Sharp, 
gnawing,  constant  pain  increasing  one-half  to  one  hour  after  eating,  present  4.5 
centimeters  below  the  ensiform  cartilage  to  the  left  of  midline.  It  is  aggravated 
on  light  palpation.  It  seems  evident  that  there  is  an  ulcer  present.  No  pain  in 
right  iliac  fossa.  No  palpable  masses.  No  hernia?.  No  adenitis.  Genitalia  and 
extremities,  negative.     Blood  pressure — systolic  no,  diastolic  So. 

Operation. — Dec.  9,  191 2.  Dr.  Deaver.  Upper  right  rectus  incision.  Peri- 
toneum opened.  Adhesions  found  between  the  great  omentum  and  parietal 
peritoneum.  Liver  adherent  to  the  parietal  peritoneum.  Peritoneum  clamped 
to  towels.  Gall-bladder  found  normal  and  connected  by  adhesions  to  the  hepatic 
flexure  of  the  colon  and  the  gaslro-colic  omentum.  Adhesions  also  found  between 
the  omentum  and  the  duodenum.  Pancreatic  lymph-nodes  were  enlarged.  Pylo- 
rus patulous.  Adhesions  between  the  jejunum  and  the  under  surface  of  the. 
transverse  colon.  Lesser  peritoneal  cavity  opened  through  the  gastro-colic  omen- 
tum and  mass  found  in  the  tail  of  the  pancreas.  Mass  found  to  be  a  cyst  the  size  of 
a  small  lemon  in  the  tail.  The  cyst  excised  (Fig.  170).  Rubber  dam  drainage. 
Opening  in  the  transverse  meso-colon  and  the  gastro-colic  omentum  closed  with 
single  iodin  gut.  One  piece  of  rubber  dam  to  the  stump  of  the  pancreas.  Wound 
closed  to  drainage. 

Recoverj'  was  uneventful,  and  patient  was  discharged  January  18,  1913. 


CHAPTER  XXIII 
SURGERY  OF  THE  SPLEEN 

Anatomy 

Position. — The  spleen  occupies  a  position  in  the  posterior  portion 
of  the  left  upper  abdomen  behind  and  shghtly  to  the  left  of  the  cardiac 
end  of  the  stomach.  Its  long  axis  is  nearly  parallel  to  the  course  of  the 
ribs.  Its  posterior  boundary  is  at  a  point  3  to  5  cm.  external  to  the 
vertebras,  and  it  extends  to  the  mid-axillary  line  anteriorly.  Its  upper 
end  is  opposite  the  spine  of  the  ninth  dorsal  vertebra,  and  its  lower  end 
is  at  the  level  of  the  first  or  second  lumbar  vertebra.  The  phrenic 
surface  lies  beneath  the  ninth,  tenth  and  eleventh  ribs. 

Sxirface  Anatomy. — The  normal  area  of  splenic  dullness  extends 
in  the  mid-axillary  line  longitudinally  from  the  ninth  to  the  eleventh 
rib,  and  transversely  from  the  mid-axillary  to  the  posterior  axillary 
line. 

Appearance,  Size  and  Shape. — The  spleen  is  of  a  dark  red  or 
purplish  color  and  has  an  average  weight  of  about  195  grams.  The 
size  varies  somewhat,  being  greater  at  the  height  of  digestion  as  a 
result  of  congestion.  The  shape  depends  largely  on  the  surrounding 
viscera  and  is  best  ascertained  by  hardening  in  situ,  by  which  means 
one  inconstant  and  three  constant  surfaces  are  presented  for  study. 
These  surfaces  are  named  from  the  organs  with  which  they  are  in  contact. 

The  phrenic  surface  is  the  outer  and  posterior  convex  surface  lying 
beneath  the  diaphragm.  It  ends  in  front  at  the  anterior  border, 
which  is  particularly  well  marked  below  the  level  of  the  hilum  and  con- 
tains one,  two  or  three  notches,  a  diagnostic  sign  in  enlarged  spleen. 
The  anterior  border  separates  the  phrenic  and  gastric  surfaces. 

The  renal  surface  rests  against  the  anterior  portion  of  the  upper 
end  of  the  left  kidney  and  suprarenal  capsule.  This  surface  does  not 
extend  as  high  as  the  phrenic  surface.  The  tail  of  the  pancreas  is 
sometimes  in  contact  with  this  portion  of  the  spleen,  and  sometimes 
with  the  gastric  surface.  The  renal  and  phrenic  surfaces  are  separated 
by  the  rounded  posterior  border  of  the  spleen. 

The  gastric  or  anterior  surface  is  concave  and  is  in  contact  with 
the  fundus  of  the  stomach.     This  surface  contains  the  hilum,  a  fissure 

717 


7l8  SURGERY   OF   THE    SPLEEN 

for  the  vessels,  and  at  its  lower  portion  is  in  contact  with  the  splenic 
flexure  of  the  colon,  unless  there  is  a  basal  surface. 

The  basal  surface  when  present  is  a  small  flattened  area  on  the 
inferior  pole  of  the  spleen  resting  on  and  being  supported  by  the  splenic 
flexure  of  the  colon. 

Blood-vessels. — The  splenic  artery  is  a  branch  of  the  celiac  axis. 
It  is  relatively  very  large  for  the  organ  it  supplies,  and  its  course 
is  quite  tortuous.  At  the  level  of  the  tail  of  the  pancreas  it 
runs  foward  in  the  Keno-renal  ligament,  to  break  up  into  several 
branches  which  enter  the  hilum  one  above  another  and  anterior  to 
the  veins.  These  vessels  ramify  through  the  connective-tissue 
trabeculae  of  the  spleen  and  do  not  anastomose.  The  branch  that 
enters  near  the  upper  pole  of  the  spleen  is  given  off  first  from  the  main 
trunk  and  supplies  several  small  branches  to  the  stomach  (vasa  brevia). 
The  gastro-epiploica  sinistra  is  given  off  from  the  splenic  artery  just 
before  it  divides  into  its  terminal  branches. 

The  splenic  veins  are  formed  in  the  fibrous  trabeculae.  They 
join  to  form  several  large  branches  which  emerge  from  the  hilum 
and  unite  to  form  the  splenic  vein  behind  and  below  the  artery.  The 
splenic  and  superior  mesenteric  veins  unite  to  form  the  portal  vein. 
This  fact  accounts  for  the  splenic  congestion  and  enlargement  associated 
with  cirrhosis  of  the  Hver. 

The  lymphatics  emerge  from  the  hilum  and  empty  into  nodes 
at  the  tail  of  the  pancreas. 

The  nerves  come  from  the  solar  plexus  and  enter  the  spleen  with  the 
arteries. 

Ligaments. — The  spleen  is  enveloped  in  peritoneum  except  where 
the  ligaments  meet  at  the  hilum  to  form  the  pedicle.  These  ligaments 
are  folds  of  peritoneum  which  transmit  the  blood-vessels  (Fig.  196,  p. 
801). 

When  the  surgeon's  hand  is  introduced  through  an  abdominal 
incision  and  passes  over  the  anterior  surface  of  the  stomach  to  the 
fundus,  it  encounters  the  spleen.  The  fold  of  peritoneum  thus  felt, 
which  joins  the  spleen  to  the  stomach,  is  the  gastro-splenic  ligament.  In 
it  run  the  vasa  brevia,  branches  of  the  splenic  artery  to  the  fundus  of  the 
stomach.  If  the  surgeon  carries  his  hand  still  further  to  the  patient's  left, 
it  will  pass  between  the  spleen  and  the  inferior  concave  surface  of  the 
diaphragm.  The  fold  of  peritoneum  that  arrests  the  fingers  as  they  pass 
behind  the  spleen  toward  the  spinal  column,  is  the  lieno-renal  ligament. 
If  one  hand  is  placed  in  this  situation,  and  the  tips  of  the  other  fingers 
are  placed  anteriorly  on  the  gastro-splenic  ligament,  the  pedicle  of  the 
spleen,  with  all  its  contained  vessels  will  lie  between  the  two  hands.     If 


PHYSIOLOGY  719 

the  fingers  are  passed  up  over  the  external  convex  surface  of  the  spleen 
to  its  upper  pole  they  will  here  encounter  the  suspensory  hgament  of  the 
spleen,  the  lieno- phrenic  ligament,  which  binds  it  to  the  diaphram.  If 
this  is  severed,  the  spleen  may  be  drawn  down  from  beneath  the  dia- 
phragm and  sometimes  may  be  brought  into  the  abdominal  incision. 

Relations. — From  the  description  given  above  it  is  seen  that  the 
spleen  is  in  relation  with  the  following  structures:  Externally  and  above 
with  the  diaphragm,  and  above  this  with  the  pleura,  the  lung,  and  the 
ninth,  tenth  and  eleventh  ribs.  Anteriorly  with  the  stomach.  Inter- 
nally with  the  left  kidney  and  suprarenal  capsule.  Inferiorly  with  the 
splenic  iiexure  of  the  colon. 

It  is  important  to  remember  these  relations  to  surrounding  organs 
when  dealing  with  an  injury  of  the  spleen  since,  especially  in  cases  of 
penetrating  wounds,  one  or  more  of  the  surrounding  structures  may  be 
injured. 

Anatomical  Anomalies. — Accessory  spleens  are  of  two  kinds,  those 
consisting  of  true  splenic  tissue,  and  those  having  the  structure  of 
hemolymph  glands.  The  former  are  true  accessory  or  supernumerary 
spleens;  usually  they  are  joined  by  connective  tissue  to  the  anterior 
border  of  the  spleen  from  which  they  have  been  cut  off  during  fetal  life. 
Occasionally  these  masses  of  splenic  tissue  are  found  free  in  the  great 
omentum,  in  the  transverse  mesocolon  or  in  the  gastro-splenic  omentum 
near  the  hilum  of  the  spleen.  Their  significance  is  unknown.  Acces- 
sory spleens  resembling  hemolymph  glands  have  the  same  distribution 
as  the  true  accessory  spleens  and  in  addition  are  said  sometimes  to  be 
found  within  the  tail  of  the  pancreas.  Usually  they  are  about  the  size 
of  a  pea,  and  vary  in  number  from  fifteen  to  twenty,  although  much 
larger  numbers  have  been  reported. 

Congenital  absence  of  the  spleen,  is  excessively  rare,  but  has  occurred. 

Variations  in  Size. — The  spleen  may  be  very  small,  no  larger  than  a 
walnut,  and  all  variations  from  this  to  the  normal  size  occur. 

Lobulated  and  abnormal  shape  has  been  noted  occasionally,  but 
appear  to  have  no  surgical  interest. 

Movable  spleen  is  a  pathological  condition  and  is  described  at 
page  728. 

Physiology 

Various  functions  have  been  attributed  to  the  spleen,  but  our 
knowledge  of  none  of  them  is  very  definite.  Some  theories  are  sup- 
ported by  a  certain  amount  of  experimental  evidence  while  others  owe 
their  acceptance  to  the  fact  that  they  have  not  yet  been  disproved. 


720  SURGERY  OF  THE  SPLEEN 

The  functions  of  the  spleen  are  best  studied  by  considering  first  the 
results  of  its  removal. 

The  results  of  splenectomy  clearly  demonstrate  that  the  functions 
of  the  spleen,  whatever  they  may  be,  readily  are  assumed  by  other 
organs.  The  changes  following  excision  of  a  normal  spleen  can  be 
studied  only  by  animal  experimentation,  although  a  certain  amount  of 
useful  information  is  obtained  after  splenectomy  in  human  beings  for 
injury  to  the  normal  organ.  In  the  latter  cases,  however,  the  or- 
ganism has  to  overcome  the  effects  of  severe  injury  and  hemorrhage,  as 
well  as  the  loss  of  the  spleen,  and  the  various  factors  are  hard  to  differ- 
entiate. Noguchi  (191 2)  recorded  the  removal  of  a  normal  spleen  be- 
cause of  its  intimate  adhesions  to  a  lipoma  which  was  being  excised. 
The  patient  was  a  man  forty-two  years  of  age,  and  his  blood  did  not 
return  to  normal  for  five  or  six  years  after  the  splenectomy;  at  first 
there  was  a  decrease  of  the  polynuclear  leukocytes,  and  their  place  was 
taken  by  lymphocytes  and  eosinophile  cells.  The  results  of  splenec- 
tomy for  disease  of  the  spleen  give  no  reliable  information,  as  the  splenic 
function  practically  has  disappeared  and  compensation  has  occurred 
before  operation. 

The  blood  changes  following  excision  of  the  spleen  may  be  sum- 
marized as  follows: 

Diminution  of  the  red  blood  cells. 

Disproportionate  decrease  in  hemoglobin. 

Leukocytosis. 

Eosinophilia  and  lymphocytosis. 

These  changes  are  transitory,  reaching  their  ma.ximum  in  a  few 
weeks  or  months;  a  gradual  return  to  normal  then  occurs.  But  lympho- 
cytosis and  eosinophilia  may  develop  late  and  persist  for  some  time  or 
may  be  absent.  No  conclusions  of  any  practical  value  can  be  drawn 
from  these  changes.  Infection  is  responsible  for  many  of  the  abnormal 
results  of  splenectomy  in  human  beings. 

After  splenectomy  there  is  also  developed  an  increased  resistance  of 
the  red-blood  cells  to  hemolysis;  and  a  lessened  tendency  to  hemoglobinuria 
and  jaundice  after  adiministration  of  hemolytic  agents  (Bottazzi, 
1894;  Pearce,  Krumlihaar  and  Frazicr,  191S). 

The  Blood-forming  Function  of  the  Spleen. — The  fetal  spleen 
manufactures  red  blood  cells  but  there  is  no  direct  evidence  to  show  that 
this  function  is  normall>-  maintained  in  post-uterine  Ufe. 

In  cases  of  severe  anemia  there  are  in  the  spleen  collections  of  cells 
resembhng  myeloid  tissue,  a  fact  which  strongly  suggests  that,  in  these 
conditions,  it  is  actively  engaged  in  the  formation  of  red  blood  cells 


METABOLIC    FUNCTIONS  721 

(Meyer  and  Heineke).  The  administration  of  pyridin  to  rabbits  results 
in  the  formation  of  areas  in  the  spleen  which  closely  resemble  the 
collections  of  hematogenetic  cells  in  the  normal  rabbit  embryo.  Pyrid- 
in causes  anemia  by  great  destruction  of  blood  and  its  mode  of  action 
probably  resembles  that  of  the  cause  of  primary  pernicious  anemia 
(Morris,  1907). 

In  a  case  of  splenomegaly  with  sclerosis  of  the  bone  marrow,  reported 
by  Donhauser  (1908),  the  spleen  contained  islands  of  what  he  con- 
sidered active  hematoplastic  tissue,  the  bone  marrow  having  lost  its 
bone-forming  function  as  a  result  of  sclerosis. 

These  observations  are  sufficient  evidence  to  warrant  the  assump- 
tion that  in  certain  pathological  conditions  the  spleen  reverts  to  its 
fetal  blood-forming  function.  That  the  regeneration  of  blood  after  hemor- 
rhage does  not  depend  on  the  spleen  to  any  extent  is  shown  by  the  fact 
that  regeneration  takes  place  as  quickly  in  splenectomized  as  in  normal 
animals  (Freytag,  1908). 

While  the  red- cell-forming  function  of  the  spleen  is  disputed, 
there  is  little  reason  to  doubt  that  this  organ  is  concerned  in  the  for- 
mation of  lymphocytes,  in  common  with  the  other  lymphatic  structures 
of  the  body. 

Hemolysis  and  Blood  Cleansing. — There  is  no  direct  evidence 
to  prove  that  the  spleen  is  a  hemolytic  organ,  though  this  is  generally 
believed.  It  contains  large  phagocytes  in  which  are  disintegrating 
red  cells  or  particles  of  pigment,  as  well  as  pigment  free  in  the  pulp. 
This  pigment  deposit  and  red  blood  cell  destruction  are  greatly  in- 
creased in  certain  severe  anemias.  There  is  also  free  in  the  spleen 
a  large  percentage  of  organic  iron.  These  facts  suggest  that  the 
spleen  either  destroys  the  erythrocytes,  or,  more  probably,  acts  as  a 
mechanical  filter  and  takes  up  the  remains  of  the  red  blood  cells, 
causes   their  disintegration   and   again  puts   the  iron  into   solution. 

Metabolic  Functions  of  the  Spleen. — Organ  of  Iron  Metabolism. 
Experiments  show  that  the  total  ehmination  of  iron  in  splenectom- 
ized but  otherwise  normal  dogs  is  considerably  greater  than  in  dogs 
with  spleens.  This  relation  is  maintained  whether  the  dogs  are 
starved  or  well  fed  on  meat.  From  these  facts  it  may  be  concluded 
that  the  spleen  is  an  organ  of  iron  metabolism,  serving  to  preserve 
for  the  use  of  the  organism  the  iron  which  is  liberated  by  the  meta- 
bolism of  the  body. 

Influence  on  Growth. — Grossenbacher  concluded  from  the  results 
of  experiments  on  puppies,  that  the  spleen  exercises  no  appreciable 
influence  on  growth,  differing  therefore  from  the  thyroid  and  thymus 

46 


722  SITRGERY    OF   THE    SPLEEN 

in  that  its  presence  or  absence  does  not  definitely  influence  the  course 
of  Hfe. 

Protection  of  the  Organism  against  Infection. — Hubbard  (1909), 
after  reporting  his  own  experiments  on  the  resistance  of  guinea-pigs  to 
staphylococcus  pyogenes  aureus  infection  after  splenectomy,  and 
reviewing  five  other  communications,  concludes  "that  the  removal 
of  the  spleen  does  not  alter,  practically,  the  individual's  suscep- 
tibility to  infection  and  that  its  functions  in  this  respect,  if  they  do 
actually  exist,  on  its  removal  are  readily  taken  up  by  other  organs." 

Almost  nothing  is  known  of  the  functions  of  the  spleen  and  the 
cause  of  its  enlargement  in  various  infectious  diseases  and  intoxications. 
This  enlargement  is  supposed  to  indicate  some  protective  action  but 
definite  knowledge  is  lacking. 

Manufacture  of  an  Internal  Secretion. — There  is  a  theorj-,  supported 
by  the  experimental  work  of  Schiff,  Herzen,  and  others,  that  the 
spleen  elaborates  an  enzyme  which  acts  on  the  trypsinogen  contained 
in  the  pancreas  and  converts  it  into  trypsin.  That  this  function, 
if  it  does  exist,  is  of  little  moment  is  demonstrated  by  the  results  of 
experiments  with  the  fresh  pancreatic  juice  of  splenectomized  animals. 
It  was  shown  that  this  contained  trypsin  in  an  active  form  (Pawlow). 

In  common  with  various  other  organs,  the  liver,  pancreas,  lungs, 
etc.,  the  spleen  contains  a  ferment;  this  is  known  as  adenase,  and  is 
capable  of  converting  adenin  into  hypoxanthin.  Its  significance  is 
unknown. 

Uric  acid  is  present  in  the  spleen  and  it  has  been  suggested  that 
it  is  formed  as  a  result  of  proteid  metabolism,  but  Chittenden  and 
Mendel  as  the  result  of  their  experiments  say,  "there  is  no  evidence 
that  the  spleen  exerts  any  special  influence  on  either  carbohydrate 
or  proteid  metabolism  in  general." 

Movements  of  the  Spleen. — The  nerves  supplying  the  spleen 
are  derived  from  the  sympathetic;  their  stimulation  causes  contraction; 
and  their  section  causes  expansion  of  the  spleen. 

Roy  (1880-82)  showed  that  the  spleen  of  the  dog  contracts  and 
relaxes  rhythmically  about  once  a  minute.  It  is  supposed  that  these 
contractions  keep  up  the  circulation  and  make  it  independent  of  the 
general  blood  pressure.  After  a  meal  the  spleen  slowly  expands, 
reaching  its  maximum  size  in  about  five  hours,  and  then  slowly  returns 
to  normal.  Relaxation  of  the  muscles  in  the  trabecule  and  vasodilata- 
tion are  supposed  to  cause  this  enlargement. 

The  relation  between  these  movements  and  the  function  of  the 
spleen  has  not  been  discovered. 


diagnosis  of  splenic  enlargement  723 

General  Consideration  of  Enlargements  of  Spleen 

^lost  of  the  conditions  which  are  of  surgical  interest  cause  an 
enlargement  of  the  spleen;  and  it  is  convenient  to  consider  the  physical 
signs  of  such  enlargements  in  this  place,  before  discussing  the  different 
diseases  of  this  organ. 

As  the  spleen  enlarges  it  emerges  from  beneath  the  ribs  about 
the  level  of  the  ninth  costo-chondral  junction.  Further  enlargement 
follows  the  same  line,  and  an  hypertrophied  spleen  always  is  in  the 
left  abdomen  until  it  reaches  the  level  of  the  umbilicus.  Further 
enlargement  carries  the  splenic  tumor  across  the  middle  line  as  well 
as  downward  on  the  left  side  toward  the  pelvic  brim.  The  physical 
signs  vary  with  the  degree  of  enlargement. 

Inspection. — If  the  abdominal  wall  is  thin  the  enlarged  spleen, 
particularly  its  lower  border,  may  be  seen  moving  with  respiration 
below  the  costal  margin.  Otherwise  inspection  reveals  only  undue 
prominence  of  the  left  hypochondrium  over  the  region  occupied  by 
the  tumor.  The  enlargement  may  be  so  enormous  that  the  whole 
abdomen  is  distended,  but  careful  inspection  usually  shows  this  to  be 
more  marked  on  the  left  side.  If  the  lower  pole  reaches  the  pelvis 
the  tumor  does  not  move  with  respiration. 

Palpation. — The  characteristic  features  of  an  enlarged  spleen 
are  its  close  apposition  to  the  abdominal  wall,  a  sharp  inner  border, 
and  most  important  of  all,  interruption  of  its  inner  border  by  one, 
two  or  three  notches.  These  are  all  readily  felt  if  the  organ  comes 
out  from  under  the  rib  margin  to  any  extent.  Splenic  tumors  always 
grow  forward;  they  never  produce  fullness  in  the  loin.  Unless  the 
spleen  is  anchored  by  peritoneal  adhesions,  it  moves  freely  with  respir- 
ation. Another  very  characteristic  feature  is  continuance  of  the 
tumor  up  under  the  rib  margin,  closely  applied  to  the  abdominal 
wall.  It  is  possible  to  insinuate  one's  hand  between  the  ribs  and 
the  upper  border  of  all  but  the  very  largest  abdominal  tumors,  but 
splenic  tumors  unless  prolapsed  are  too  closely  apphed  to  the  abdominal 
wall  to  permit  this.  Occasionally  when  there  is  marked  perisplenitis 
a  friction  rub  may  be  felt  as  the  spleen  moves  with  respiration,  and 
adhesions  may  obscure  the  notches  and  twist  the  spleen  so  as  to  obliter- 
ate the  sharp  anterior  margin.  With  the  exception  of  these  notches, 
an  enlarged  spleen  usually  is  smooth  and  firm,  although  in  certain 
infectious  diseases  it  is  sometimes  too  soft  to  be  felt.  The  enlarge- 
ment may  be  so  slight  that  the  edge  is  just  to  be  felt  with  deep 
inspiration. 


724  SURGERY    OF    THE    SPLEEN 

Percussion. — An  enlarged  spleen  is  dull  to  percussion  up  to  the 
seventh  or  sixth  rib  or  even  higher  in  the  mid-axillary  line.  The  colon 
is  displaced  first  downward,  and  later  lies  behind  the  enlarged  spleen, 
so  that  any  resonance  due  to  it  will  be  in  the  flank  or  loin. 

Auscultation. — In  the  majority  of  splenic  tumors  auscultation  is 
negative.  If  there  is  any  perisplenitis  there  may  be  audible  a  to- 
and-fro  friction  rub.  Very  occasionally  there  is  an  audible  mur- 
mur, hemic  in  origin,  due  to  venous  dilatation.  In  obscure  cases 
it  is  well  to  outline  the  enlarged  spleen  by  auscultatory  percussion. 

Differential  Diagnosis. — Spleiuc  enlargements  have  to  be  differenti- 
ated from  various  kinds  of  abdominal  tumors,  those  in  and  about  the 
kidney  causing  the  greatest  difficulty. 

Pancreatic  Cysts. — For  physical  signs  and  diagnosis  see  page  709. 

Kidney  Tumors. — -New  growths  of  the  kidney  scarcely  ever  come 
into  close  contact  with  the  anterior  abdominal  wall,  and  even  when 
they  do  they  also  cause  marked  bugling  of  the  loin. 

Palpation. — Kidney  tumors  have  a  rounded  contour  with  no 
sharp,  notched  anterior  border.  They  cause  bulging  and  increased 
resistance  in  the  loin  when  they  are  large  enough  to  simulate  splenic 
enlargements.  The  range  of  motion  is  much  less.  The  anterior 
surface  slopes  away  from  the  abdominal  wall  as  it  approaches  the 
rib  margin  and,  except  in  the  very  largest  tumors  the  hand  can  be 
insinuated  between  the  costal  margin  and  the  upper  portion  of  the 
tumor.  An  enlarged  spleen  is  closely  applied  to  the  abdominal  wall, 
at  its  upper  pole,  and  the  hand  cannot  be  passed  above  it.  A  renal 
tumor  seldom  is  so  large  that  it  crosses  the  median  Hne.  but  this  not 
unfrequently  occurs  in  cases  of  splenic  enlargement. 

Percussion. — The  descending  colon  overhes  the  anterior  surface 
of  the  kidney  and  is  pushed  forward  when  the  kidney  enlarges.  This 
causes  an  area  of  resonance  over  the  abdominal  surface  of  the  tumor, 
while  there  is  dullness  in  the  loin.  The  reverse  is  true  in  splenic 
tumors.  But  very  occasionally  the  growth  of  a  renal  tumor  pushes 
the  colon  outward  instead  of  forward  and  the  area  of  resonance  is  in 
the  iiank  as  in  splenic  tumors;  in  such  cases  the  surgeon  must  relj'  on 
the  results  of  palpation  and  on  tests  of  the  renal  functions,  including 
catheterization  of  the  ureters,  etc. 

Auscultation  is  negative. 

Other  symptoms  and  physical  signs  are  of  importance.  The  surgeon 
should  not  forget  that  tumors  of  the  kidney  are  not  always  accompanied 
by  characteristic  renal  pain,  and  that  acute  attacks  of  perisplenitis  may 
cause  paroxysmal  pain  much  resembling  renal  colic.     The  most  impor- 


DIAGNOSIS    OF    SPLENIC   ENLARGEMENT  725 

tant  differential  signs  are  obtained  by  cystoscopy,  catheterization  of  the 
ureters  pyelography  and  careful  examination  of  the  urine.  In  certain 
cases  of  splenic  enlargement  a  differential  blood  count  clears  up  the 
diagnosis. 

Suprarenal  growths  as  a  rule  have  the  same  physical  signs  as  kidney 
tumors,  except  that  the  colon  is  very  often  pushed  downward  instead  of 
forward.  Hematuria  frequently  is  present  as  a  result  of  infiltration  of 
the  kidney  by  the  growth. 

Perinephric  Abscess. — Apart  from  the  evidences  of  suppuration,  the 
physical  signs  resemble  those  of  enlarged  kidney  more  closely  than  they 
do  those  of  splenic  enlargement.  The  urinary  and  cystoscopic  findings, 
depend  on  whether  or  not  the  kidney  substance  is  involved. 

Ovarian  Tumors. — Several  cases  are  on  record  where  a  displaced 
spleen  has  been  mistaken  for  an  ovarian  tumor,  the  mistake  being 
recognized  only  after  the  abdomen  was  opened.  When  the  spleen  is  in 
the  pelvis  and  the  notch  cannot  be  felt  by  vaginal  or  rectal  examination 
it  is  readily  seen  how  such  confusion  might  occur.  A  diagnosis  of 
prolapsed  spleen  can  be  made  only  by  feeling  the  notch  in  the  sharp 
anterior  border.  A  large  ovarian  tumor  could  scarcely  be  mistaken  for 
a  tumor  of  the  spleen  enlarging  from  its  normal  position.  The  following 
characteristics  of  an  ovarian  tumor  are  sufficient  to  make  the  diagnosis: 
The  upper  border  of  an  ovarian  tumor  seldom  is  in  actual  contact  with 
the  left  costal  margin  unless  it  reaches  also  to  the  right  costal  margin. 
Ovarian  tumors  grow  upward  from  the  pelvis  and  the  first  and  most 
prominent  enlargement  is  in  the  lower  abdomen.  They  do  not  move 
with  respiration,  and  have  no  sharp  border  with  one  or  more  notches. 
They  extend  further  across  the  middle  line  and  cause  more  symmetrical 
enlargement  of  the  abdomen.  Vaginal  examination  as  a  rule  shows  the 
tumor  in  close  association  with  a  normal  sized  uterus,  and  frequently 
the  pedicle  of  the  cyst  can  be  felt  through  the  rectum.  There  usually 
is  an  area  of  resonance  between  the  upper  border  of  dullness  over  an 
ovarian  tumor  and  the  normal  area  of  splenic  dullness. 

Growths  of  the  Splenic  Flexure. — Annular  growths  of  the  colon 
in  the  neighborhood  of  the  splenic  flexure  usually  are  malignant  and 
give  rise  to  symptoms  of  intestinal  obstruction  before  a  palpable 
tumor  develops.  Occasionally,  however,  a  diffuse  tumor  forms  in  the 
left  upper  abdomen  before  symptoms  of  obstruction  occur,  and  such  a 
tumor  may  have  to  be  differentiated  from  an  atypical  enlargement  of  the 
spleen. 

A  tumor  of  the  splenic  flexure  has  not  the  definite  shape  of  an  enlarged 
spleen,  with  its  sharp  anterior  border  showing  one  or  more  notches, 


726  SURGERY  OF  THE  SPLEEN 

nor  has  it  the  same  close  apposition  to  the  abdominal  wall  throughout 
its  extent.  It  is  usually  dull  to  superficial,  but  resonant  to  deep.per- 
cussion.  If  fixed  with  adhesions  it  does  not  exhibit  the  same  degree 
of  mobihty  during  respiration  as  does  the  spleen.  If  not  fixed  its 
position  changes  to  a  marked  extent  with  changes  in  the  patient's  pos- 
ture. Sooner  or  later  such  a  tumor  gives  rise  to  symptoms  of  intesti- 
nal obstruction  and  metastasis,  but  the  diagnosis  should  be  made  and 
operation  undertaken  before  these  occur.  Roentgenological  study  will 
usually  exclude  splenomegaly. 

Tuberculous  Peritonitis. — In  the  fibrous  form  of  tuberculous 
peritonitis  tumors  of  various  sizes  and  shapes  are  found  in  dift'er- 
ent  parts  of  the  abdomen.  When  such  a  tumor  mass  is  formed  in 
the  left  upper  abdomen  and  particularly  if  it  is  adherent  to  the  spleen 
it  may  closely  simulate  in  general  outline  a  splenic  tumor.  Attention 
to  the  following  points  serves  to  distinguish  one  from  the  other: 

The  range  of  movement  in  a  tuberculous  tumor  usually  is  lim- 
ited by  adhesions  to  the  abdominal  wall.  Although  the  anterior 
border  may  be  well  defined  it  seldom  exhibits  a  notch  similar  to  those 
of  the  spleen.  There  usually  is  an  area  of  resonance  between  the 
tumor  and  the  normal  area  of  splenic  dullness.  Moderate  ascites 
often  is  present  in  tuberculous  peritonitis,  but  may  also  occur  in  some 
forms  of  splenomegaly.  Careful  search  nearly  always  will  reveal  other 
tumors  or  indefinite  areas  of  consolidation  in  different  parts  of  the 
abdominal  cavity.  The  tubercuHn  reaction  is  of  great  value;  von 
Pirquet's  skin  test  is  sufiicient  in  very  young  children,  but  in  adults  the 
hypodermic  injection  of  old  tubercuHn  gives  more  accurate  results. 

Malignant  Peritonitis. — In  this  condition  the  physical  signs  and 
symptoms  are  very  much  like  those  of  tuberculous  peritonitis,  except 
that  it  is  not  likely  that  the  tuberculin  reaction  will  be  positive.  In 
most  cases  other  tumor  masses  are  readily  discoverable  in  various 
portions  of  the  abdominal  cavity. 

Fecal  Impaction. — Except  that  it  may  give  rise  to  a  tUmor  in 
the  left  hypochondrium  there  is  very  little  resemblance  between  a 
fecal  impaction  and  an  enlarged  spleen.  The  irregular,  indefinite 
shape,  symptoms  of  temporary  obstruction  alternating  with  diarrhea, 
pitting  on  pressure,  movability  and  absence  of  the  usual  physical  signs 
of  splenic  enlargement,  serve  to  make  the  differentiation  comparatively 
easy. 

Sarcoma  of  the  Stomach. — Primary  sarcoma  of  the  stomach  is 
rare.  When  it  occurs  it  is  frequently  situated  at  the  fundus,  infiltrates 
the  whole  stomach  wall,  and  may  cause  a  very  large  tumor  in  the  upper 


CAUSES    OF    SPLENOMEGALY  727 

abdomen.  As  previously  noted  (page  282)  it  is  accompanied  by  en- 
largement of  the  spleen  in  about  15  per  cent,  of  cases. 

Its  distinguishing  characteristics  are:  resonance  on  percussion  over 
the  tumor;  changes  of  position  during  examination  and  when  the  patient 
changes  his  posture;  a  position  further  to  the  right  than  is  usual  with  an 
enlarged  spleen,  that  is,  the  right  border  may  be  beyond  the  middle  line 
although  the  tumor  does  not  extend  below  the  umbihcus;  definite 
gastric  symptoms;  and,  while  there  is  a  sharp  border,  it  is  not  notched 
as  a  rule.  The  course  of  such  a  case  is  rapidly  progressive  to  a  fatal 
termination. 

Retroperitoneal  tumors  are  not  easily  confounded  with  those 
of  splenic  origin.  Retroperitoneal  growths  usually  present  within 
the  circle  formed  by  the  large  bowel,  offering  to  percussion  a  dull 
area  surrounded  by  intestinal  tympany.  Inflation  of  the  colon  and 
stomach,  examination  in  the  Trendelenburg  and  knee-chest  positions, 
should  be  adopted  in  obscure  cases. 

Pletiral  Effusion,  when  massive,  on  the  left  side,  may  occasionally 
cause  inversion  of  the  diaphragm,  with  development  of  a  tumor  in  the 
region  of  the  spleen.  "The  tumor  has  a  pecuUar  bulky  feel,  is  tender 
to  touch,  does  not  move  with  respiration,  has  the  shape  neither  of  the 
spleen  nor  of  the  kidney,  and  appears  to  have  a  deep  attachment. 
Its  true  nature  is  revealed  after  aspiration  of  the  chest,  when  it  will  be 
found  to  disappear"  (Riesman,  1920). 

Causes  of  Enlargement  of  the  Spleen 

There  are  two  groups  of  cases  associated  with  splenomegaly,  (i) 
Those  in  which  the  blood  changes  are  distinctive.  (2)  Those  in  which 
the  blood  changes  are  not  distinctive. 

A  complete  blood  examination  is  essential  in  every  case  of  splenic 
enlargement.  A  positive  diagnosis  never  can  be  made  without  it. 
By  this  means  Group  i  is  differentiated  from  Group  2  with  compara- 
tively Uttle  difliculty.  With  the  exception  of  certain  cases  to  be  con- 
sidered later  (see  page  752)  operative  interference  is  absolutely 
contraindicated  in  cases  included  in  Group  i,  and  therefore  they 
have  no  place  in  the  consideration  of  splenomegaly  viewed  from  a 
surgical  standpoint. 

Group  I.  Cases  of  Splenic  Enlargement  with  Distinctive  Blood 
Changes. — This  comprises  most  cases  of  malaria,  the  leukemias, 
pernicious  anemia,  splenomegalic  polycythemia,  typhoid  fever,  and 
kala  azar. 


728  SURGERY    OF    THE    SPLEEN 

Group  2.  Cases  of  Splenic  Enlargement  without  Distinctive 
Blood  Changes. — This  comprises  three  divisions:  (a)  cases  in  which 
splenectomy  is  advisable  or  necessary;  (b)  those  in  which  it  is  occa- 
sionally indicated;  and  (c)  those  in  which  it  is  contraindicated. 

The  hrst  division,  in  which  splenectomy  is  advisable  or  necessary, 
includes: 

1.  Movable  spleen. 

2.  Cysts. 

3.  Primary  tumors. 

4.  Primary  tuberculosis. 

5.  Abscess. 

6.  Banti's  disease  and  its  subvarieties. 

The  second  division  in  which  splenectomy  is  occasionally  indicated, 
comprises  some  cases  of: 

7.  Hemolytic  Icterus  (Hereditary  and  family  forms  of  spleno- 
megaly) . 

8.  Syphihs. 

9.  Malaria. 

10.  Pernicious  anemia. 

11.  Cirrhosis  of  the  Hver. 

The  third  division  is  of  surgical  interest  only  from  the  standpoint 
of  differential  diagnosis,  since  splenectomy  is  contraindicated.  It 
includes  enlargements  due  to: 

12.  Congestion  (active  or  passive)  and  inflammation. 

13.  Infarct  and  thrombosis. 

14.  Infectious  fevers. 

15.  Hodgkin's  disease. 

16.  Amyloid  disease. 

17.  Rickets.    ■ 

18.  Perisplenitis. 

19.  Pseudoleukemia. 

20.  Obstruction  of  the  inferior  vena  cava  above  the  entrance 
of  the  hepatic  veins  by  mediastinal  tumors,  pulmonary 
fibrosis,  chronic  heart  disease,  etc. 

The  diagnosis  of  some  of  these  from  surgical  conditions  is  obvious. 
The  others  will  be  considered  with  the  conditions  which  they  simulate. 

Movable  Spleen 

A  movable  spleen  is  also  known  as  a  wandering,  a  floating,  or  an 
ectopic  spleen.  The  terms  prolapse  and  splenoptosis  are  also  applied. 
A  dislocated  spleen  is  one  which  is  rt.xed  in  an  abnormal  position. 


MOVABLE    SPLEEN  729 

Etiology. — Prolapse  of  the  spleen  occurs  most  frequently  in  women; 
thirteen  of  fourteen  cases  noted  in  our  first  edition  were  in  women. 
Elongation  of  the  ligaments  always  is  associated  with  any  marked 
degree  of  splenic  mobility.  This  lengthening  may  be  congenital  or 
acquired.  Of  the  congenital  condition  we  know  nothing.  Acquired 
lengthening  sometimes  is  said  to  result  from  trauma,  but  it  is  probable 
that  the  injury  leads  to  abdominal  examination,  and  that  the  dis- 
covery is  then  made  of  a  prolapse  of  the  spleen  which  has  existed  without 
symptoms  for  some  time.  It  is  possible,  however,  that  acute  displace- 
ments may  result  from  rupture  of  the  ligaments.  Cases  of  movable 
spleen  which  produce  no  symptoms  usually  are  discovered  incidentally 
during  examination  for  other  conditions.  General  enteroptosis  may 
include  descent  of  the  spleen,  without  necessarily  any  increase  in  the 
length  of  the  pedicle.  Increased  weight  is  a  factor  in  etiology,  although 
in  the  majority  of  cases  of  splenomegaly  perisplenic  adhesions  and 
hypertrophy  of  the  ligaments  keep  the  organ  in  place.  Thus  the  en- 
larged spleen  of  leukemia,  splenic  anemia,  malaria,  etc.,  usually  does 
not  prolapse.  Yet  of  fourteen  cases  of  splenectomy  for  wandering 
spleen  mentioned  in  the  first  edition  of  this  work,  four  were  associated 
with  malarial  hypertrophy  and  three  with  idiopathic  enlargement. 
Elongation  of  the  pedicle  to  25  cm.  is  reported  and  it  often  is  long 
enough  to  permit  the  spleen  to  drop  into  either  iliac  fossa,  or  into  the 
pelvis. 

Pathology. — A  movable  spleen  may  vary  in  size  from  normal 
almost  to  any  degree  of  enlargement.  The  pathological  conditions 
in  such  a  spleen  are  of  two  kinds,  those  the  result  of  the  displace- 
ment, and  those  occurring  independently.  Among  the  latter  are 
morbid  changes  the  result  of  fortuitous  diseases  such  as  malaria  and 
leukemia.  These  changes  are  characteristic  and  well  known  and 
need  not  be  considered  in  connection  with  the  pathology  of  movable 
spleen.  Those  changes  produced  by  displacement  are  caused  by 
twisting  of  the  pedicle  and  interference  with  the  blood  supply. 

Acute  torsion  occurs  suddenly  and  the  twist  is  tight,  causing 
necrosis  of  the  spleen  and  thrombosis  of  the  splenic  vessels,  unless 
operation  is  immediately  undertaken. 

Chronic  Torsion. — When  twisting  occurs  slowly,  the  twist  is  loose 
and  causes  only  gradual  interference  with  the  blood  supply  resulting 
in  enlargement  from  congestion  of  the  spleen,  hemorrhage  into  its 
substance  and  consequent  increase  of  fibrous  tissue.  In  late  cases 
these  changes  may  be  succeeded  by  sclerosis  and  atrophy  with  con- 
sequent diminution  in  size. 


730  SURGERY    OF   THE   SPLEEN 

Intermittent  attacks  of  twisting  have  effects  similar  to  those  seen 
in  cases  of  chronic  torison.  Such  attacks  in  a  wandering  spleen 
usually  cause  perisplenitis  and  the  formation  of  adhesions  to  the 
structures  with  which  it  comes  into  contact. 

The  degree  of  twisting  in  reported  cases  varies  from  one  incomplete 
to  four  complete  turns. 

Sjmiptoms. — Simple  uncomplicated  mobility  causes  little  or  no 
disturbance  and  the  diagnosis  is  usually  made  incidentally  during 
routine  abdominal  examination.  Occasionally  indefinite  gastro-intes- 
tinal  symptoms  are  associated  with  splenic  mobility  and  may  be 
considered  the  consequence  of  such  displacement.  Intermittent 
attacks  of  jaundice  and  functional  disturbances  in  surrounding  organs 
may  result  from  the  traction  of  an  enlarged  movable  spleen.  Digestive 
disturbances,  constipation  and  even  partial  intestinal  obstruction 
may  result  from  dragging  of  the  pedicle.  But  the  only  definite  symp- 
toms directly  attributable  to  prolapse  of  the  spleen  are  those  arising 
from  twists  of  the  pedicle. 

Acute  Torsion. — The  primary  and  most  important  symptom 
of  this  condition  is  severe  paroxysmal  pain  and  tenderness  in  the 
left  hypochondrium.  The  pain  may  give  rise  to  nausea  and  vomiting 
and  a  certain  amount  of  shock,  with  increase  in  the  pulse  rate.  If 
unrelieved  the  obstruction  to  the  blood  supply  causes  necrosis  of 
the  spleen  and  the  development  of  locahzed  peritonitis.  Death 
from  sepsis  or  the  formation  of  a  localized  abscess  may  result. 

Chronic  Torsion. — The  twist  in  the  pedicle  not  being  so  tight 
as  to  cause  complete  obstruction  of  the  vessels,  the  symptoms  are 
less  sudden  and  severe  in  onset.  Torsion  through  less  than  three- 
fifths  of  a  circumference  seldom  produces  sjntnptoms.  Intermittent 
attacks  of  pain  associated  with  local  tenderness  are  the  only  symp- 
toms of  moment.  These  attacks  may  occur  spontaneously  or  result 
from  some  sudden  exertion  or  movement.  Attacks  of  perisplenitis 
cause  the  same  symptoms  and  are  the  cause  of  the  formation  of  the 
adhesions  that  fix  the  spleen  in  abnormal  positions  {dislocated  spleen). 
Rectal  tenesmus  is  caused  by  impaction  of  a  dislocated  spleen  in  the 
pelvis.  Attacks  of  perisplenitis  or  twist  of  the  pedicle  usually  are 
accompanied  by  elevation  of  temperature  and  increased  pulse  rate. 

Diagnosis. — In  uncomplicated  cases  of  movable  spleen  the  organ 
is  not  enlarged  to  any  extent  and  presents  well-marked  characteristics. 
It  retains  its  shape,  a  sharp  anterior  border,  and  one  or  more  distinct 
notches.  The  normal  area  of  splenic  dullness  is  absent.  By  putting 
the  patient  in  the  dorsal  position,  the  spleen  can  be  easilj'  pushed 


MOVABLE    SPLEEN  73 1 

up  under  the  left  rib  margin,  where  it  will  remain  until  the  patient 
changes  her  position. 

Twist  of  the  pedicle  causes  increase  in  the  size  of  the  tumor,  which 
becomes  acutely  tender.  Rigidity  of  the  abdominal  muscles  is  pro- 
nounced but  not  general,  being  confined  to  the  area  covering  the 
displaced  spleen.  If  there  are  no  adhesions  the  characteristics  of 
the  splenic  outline  are  recognizable,  although  a  diagnosis  of  movable- 
kidney  is  frequently  made.  As  a  rule  the  displacement,  the  swelling 
and  the  formation  of  an  inflammatory  exudate  obscure  the  physical 
signs  and  render  diagnosis  difficult.  Cases  are  reported  in  which  a 
dislocated  spleen  has  simulated  appendiceal  abscess,  twisted  ovarian 
cyst,  and  pus  tube.  If  the  spleen  is  impacted  in  the  pelvis,  the  correct 
diagnosis  is  impossible  unless  the  notch  can  be  felt  through  the  vagina 
or  rectum,  and  even  then  the  infrequency  of  the  condition  will  cause 
a  doubt  as  to  the  probabihty  of  such  a  tumor  being  the  spleen. 

Differential  Diagnosis. — In  non-adherent  cases  the  only  con- 
fusion in  diagnosis  arises  from  the  question  of  movable  kidney,  the 
great  frequency  of  which  condition  and  its  similarity  in  symptoms 
and  physical  signs  make  a  mistake  pardonable.  But  careful  examin- 
ation for  the  splenic  notch,  attempting  to  palpate  the  kidney  indepen- 
ently  of  the  abdominal  tumor,  the  absence  of  the  urinary  changes 
which  frequently  result  from  a  kidney  crisis  and  the  different  range 
of  mobility  in  the  two  organs,  are  signs  to  be  looked  for  and  given 
due  weight  in  arriving  at  a  diagnosis.  The  splenic  artery  is  said  to 
be  palpable  in  cases  of  movable  spleen,  but  this  is  not  true  of  the 
renal  artery  when  the  kidney  is  displaced.  Forgetting  the  possibility 
of  a  movable  spleen  is  the  most  frequent  cause  of  mistake. 

The  diagnosis  of  an  adherent  misplaced  spleen  usually  is  impossible, 
since  inflammatory  exudate  obscures  the  splenic  outline,  and  the 
history  and  physical  signs  point  to  inflammation  of  the  organ  normally 
occupying  the  area  affected.  Thus  a  mass  in  the  right  ihac  fossa, 
associated  with  pain,  tenderness,  rigidity,  fever  and  leukocytosis  is 
more  likely  to  be  an  appendiceal  abscess  than  anything  else.  Likewise, 
ifthe  tumor  is  in  the  pelvis  it  simulates  ovarian  or  tubo-ovarian  disease. 

Treatment. — For  those  cases  of  movable  spleen  discovered  acciden- 
tally, no  operative  treatment  need  be  undertaken.  The  patient 
does  not  suffer  from  the  condition  and  no  harm  is  likely  to  arise.  For 
those  cases  complicated  with  twists,  perisplenitis  and  adhesions 
operative  treatment  is  indicated  and  consists  in  splenopexy  or  splenec- 
tomy, preferably  the  latter  (see  page  799).  Of  seventeen  recently 
reported  operations  for  wandering  spleen  mentioned  in  the  first  edition 


732  SURGERY  OF  THE  SPLEEN 

of  this  work  (fourteen  splenectoniies,  two  splenopexies,  and  one  explor- 
atory operation  in  which  nothing  was  done  when  the  tumor  in  the 
pelvis  was  found  to  be  the  spleen),  all  the  patients  made  uneventful 
recoveries.  Splenectomy  sometimes  is  very  difficult  on  account  of  the 
adhesions  formed  between  the  spleen  and  various  abdominal  organs. 
G.  G.  Ross  did  splenopexy  in  one  patient  with  ptosis  of  the  spleen, 
■in  the  German  Hospital,  but  symptoms  persisted  and  splenectomy 
was  eventually  required  and  proved  perfectly  successful.  In  our  first 
edition  we  tabulated  io6  cases  of  splenectomy  for  wandering  spleen, 
with  7  deaths,  a  mortality  of  6.5  per  cent.  Among  37  other  cases  of 
splenectomy  for  twisted  pedicle,  there  were  10  deaths,  a  mortality  of  27 
per  cent. 

Cysts  of  the  Spleen 

The  two  main  varieties  of  cysts  found  in  the  spleen  are  the  parasitic 
(chiefly  echinococcus)  and  the  simple,  or  non-parasitic.  One  case  of 
dermoid  cyst  of  the  spleen  was  reported  by  Andral  in  1829.  The 
entire  subject  was  reviewed  by  Fowler  (1913)  who  analyzed  82  cases  of 
all  varieties. 

Echinococcus  Cysts. — Among  native  Americans  echinococcus  dis- 
ease is  almost  unknown.  In  1901  Lyon  collected  241  cases  of  echino- 
coccus disease  reported  in  North  America.  The  nationality  of  149 
was  determined  and  among  these  there  were  only  two  Canadians  and 
one  American,  the  rest  being  foreigners  (136),  negroes  (10)  and  undeter- 
mined (92).  Of  the  241  cases  the  spleen  was  the  seat  of  disease  in  nine 
(3.7  per  cent.). 

Pathology. — Involvement  of  the  spleen  may  be  primary  or  by 
extension  from  the  gastro-splenic  omentum.  Any  portion  of  the  organ 
may  be  affected  and  it  may  contain  more  than  one  cyst,  but  each 
individual  cyst  is  unilocular.  The  size  of  the  cysts  varies;  very  often 
they  are  so  small  as  to  remain  undetected  until  autopsy,  at  other  times 
they  reach  a  size  which  necessitates  surgical  interference.  Small 
cysts  may  be  destroyed  spontaneously  and  the  remains  may  become 
calcified.  Large  cysts  may  rupture  or  become  infected.  Rupture 
leads  to  serve  toxemia  and  peritonitis,  which  may  be  fatal,  or  to  the 
danger  of  dissemination  of  the  disease  by  the  escape  of  living  parasites, 
if  the  more  serious  complications  do  not  occur.  Infection  results  in 
the  formation  of  an  abscess,  presenting  no  special  characteristics. 

Macroscopically  and  microscopically  the  cyst  presents  the  same 
appearance  and  causes  the  same  tissue  reaction  in  the  spleen  as  in 
other  organs. 


CYSTS  733 

Symptoms. — The  symptoms  are  those  of  simple  cyst.  The  "hydatid 
thrill"  is  usually  absent,  but  may  be  simulated  by  other  conditions. 

Differential  Diagnosis. — Exploratory  puncture  seldom  is  justi- 
fiable on  account  of  the  danger  of  toxemia,  infection  and  the  escape 
of  living  parasites  into  the  peritoneal  cavity.  The  finding  of  cyst 
elements  in  puncture  fluid  is  pathognomonic  but  their  absence  does 
not  exclude  the  possibihty  of  echinococcus  disease.  The  information 
obtained  by  exploratory  puncture  is  not  of  sufficient  value  to  warrant 
the  risk  incurred.  A  complement  fixation  test  may  also  be  used,  as  in 
hydatid  disease  elsewhere  in  the  body. 

Prognosis. — Cysts  of  a  large  size  are  always  a  source  of  danger. 
Rupture  or  infection  may  occur  and  are  very  serious  complications. 

Treatment. — Splenectomy  is  the  ideal  treatment  but  may  be 
impossible  on  account  of  extensive  adhesions.  Under  these  con- 
ditions formolization,  as  described  at  p.  569,  followed  by  resection  and 
drainage  should  be  undertaken.  Successful  results  from  marsupializa- 
tion have  been  reported.  Among  29  cases  of  splenectomy  for  hydatid 
cyst,  tabulated  in  our  first  edition,  there  were  6  deaths,  a  mortality 
of  20.3  per  cent. 

Simple  or  Non-parasitic  Cysts.  Causes. — Trauma  is  the  most 
frequent  cause  of  non-parasitic  cyst  of  the  spleen  and  is  the  only  etiologic 
factor  that  is  accepted  without  question.  It  gives  rise  to  a  subcapsular 
hematoma  which  subsequently  may  become  a  serous  cyst  from  deposi- 
tion of  the  solid  elements. 

Blood  Cysts. — In  addition  to  trauma,  other  causes  of  blood  cysts 
are  hemangeiomata  (p.  735),  hemorrhage  into  serous  or  lymph-cysts, 
and  hemorrhage  into  the  spleen  during  the  course  of  infectious  fevers, 
typhoid,  malaria,  etc. 

Serous  Cysls. — Serous  cysts  usually  result  from  hematomas,  but 
occasionally  their  origin  is  undetermined  and  several  theories  have 
been  advanced  to  account  for  their  development.  It  is  held  by  some 
that  a  cyst  may  result  from  degeneration  of  portions  of  the  peritoneal 
endothehum  misplaced  beneath  the  splenic  capsule  during  embryonic 
life.  Another  theory  is  that  some  of  the  splenic  pulp  is  extruded  through 
a  rent  in  the  capsule  and  that  a  cyst  is  developed  in  the  space  that  is 
left. 

Lymph-cysts. — ^Lymph-cysts  are  due  to  the  degeneration  of  lymph- 
angeiomata  or  to  the  occlusion  of  lymph-vessels  and  the  escape  of 
lymph. 

Retention  Cysts  do  not  occur  as  there  are  no  tubular  glands  in  the 
spleen. 


734  SURGERY    OF    THE    SPLEEN 

Pathology. — Blood  cysts  contain  blood  and  blood  remnants.  The 
color  varies  according  to  the  age  of  the  cyst  and  the  degree  of  alteration 
in  the  blood.  Serous  cysts  are  characterized  by  clear  fluid  contents, 
of  low  specific  gravity  (1003  to  loio),  containing  no  albumen.  Lymph- 
cysts  contain  fluid  having  the  characters  of  lymph;  it  is  clear,  straw 
colored,  has  a  high  specific  gravity  and  contains  a  large  amount 
of  albumen.  Cholesterin  in  varying  amounts  is  contained  in  the  fluid 
of  every  splenic  cyst.  When  it  is  excessive  the  cysts  are  known  as 
cholesterin  cysts. 

Non-parasitic  cysts  may  be  uni-  or  multilocular,  and  vary  in  size 
from  those  which  are  of  no  pathological  significance  to  those  contain- 
ing 2  gallons  of  fluid.  The  cyst  walls  also  vary  from  those  of  extreme 
thinness,  to  the  thickened  and  calcified  walls  of  old  cysts.  The  cysts 
are  lined  with  endothelium,  but  this  is  not  always  demonstrable  if  the 
walls  have  undergone  degeneration.  Any  portion  of  the  spleen  may 
be  involved  at  first,  but  as  the  cyst  develops  it  very  soon  becomes 
subcapsular.  Rapid  increase  usually  but  not  always  is  due  to  hemor- 
rhage into  the  cyst.  Himtington  (1907)  reported  a  case  where  a  lymph- 
cyst  increased  from  the  umbihcus  to  the  pelvic  brim  in  three  weeks. 

Adhesions  may  form  around  the  spleen  and  make  operation  very 
difficult.  Unhke  hydatid  cysts,  rupture  or  infection  scarcely  ever 
occurs  in  cases  of  simple  cyst. 

Symptoms. — Pain  is  the  most  noticeable  symptom.  It  is  due 
to  three  main  causes:  the  weight  of  the  tumor,  stretching  of  the  capsule, 
or  attacks  of  perisplenitis.  Pain  from  the  weight  of  the  tumor  varies 
in  degree  and  may  be  only  a  sense  of  fullness  and  discomfort.  Sudden 
stretching  of  the  capsule  and  attacks  of  perisplenitis  cause  severe  pain. 
Other  symptoms  result  from  dragging  on  and  interference  with  the 
function  of  neighboring  organs.  Gastric,  intestinal,  urinary,  respira- 
tory and  cardiac  disturbances  are  thus  occasioned.  In  some  reported 
cases  the  patients  have  had  chills,  although  the  malarial  parasite  was 
not  demonstrable. 

The  physical  signs  are  enlargement  of  the  left  upper  abdomen, 
a  palpable,  smooth  tumor  emerging  from  beneath  the  left  costal  margin, 
and  fluctuation.  Small  cysts  cause  no  symptoms  or  physical  signs  and 
require  no  treatment. 

Diagnosis. — The  diagnosis  is  based  on  the  physical  signs,  and 
on  the  existence  of  a  cystic  tumor  growing  from  and  intimately  asso- 
ciated with  the  spleen.  Cysts  of  the  spleen  have  been  mistaken  for 
pancreatic  cyst,  movable  kidney,  cystic  kidney,  hydronephrosis  and 
ovarian  cyst.     These  conditions  have  been  sufficiently  described. 


TUBERCULOSIS  •  73$ 

Treatment. — Surgical  treatment  is  indicated  whenever  the  cyst 
grows  rapidly  or  is  of  a  size  sufficient  to  cause  distressing  symptoms. 
Excision  of  the  cyst  with  repair  of  the  raw  area,  or  splenectomy  are  the 
accepted  methods  of  treatment  at  present.  Marsupialization  and 
incision  and  drainage  should  be  considered  obsolete.  Successful  results 
have  followed  all  forms  of  treatment,  but  splenectomy  has  been  per- 
formed oftener  than  any  other  operation.  Among  twenty-five  opera- 
tions reported  in  our  first  edition,  there  was  only  one  death. 

Tumors  of  the  Spleen 

These  are  rare.  Types  of  sarcoma  are  the  least  unusual,  but  are 
more  often  secondary  than  primary.  Fibroma,  chondroma,  osteoma, 
hemangeioma,  and  lymphangioma  have  also  been  observed. 

The  proper  treatment  of  primary  tumors  is  splenectomy. 

The  senior  author  has  done  one  splenectomy  for  primary  sarcoma, 
in  a  woman  38  years  of  age.  The  patient  left  the  hospital  in  good 
health  6  weeks  after  the  operation,  but  her  subsequent  history  is  not 
known.  Giffin  (1915)  reported  that  two  splenectomies  had  been  done 
at  the  Mayo  Clinic  for  lymphosarcoma:  one  patient  remained  well  for 
several  years  but  finally  died  with  metastases  nine  years  after  operation, 
while  the  second  patient  died  in  five  months  with  generalization  of  the 
disease.  These  cases,  in  addition  to  those  tabulated  in  our  first  edition, 
give  a  total  of  18  splenectomies  for  sarcoma,  with  3  deaths  (16  per  cent.) 

Dowd  (1915)  collected  13  cases  of  cavernous  angeioma  of  the  spleen; 
splenectomy  was  done  in  6  instances,  with  2  operative  deaths,  3  opera- 
tive recoveries,  and  i  case  in  which  the  result  was  not  recorded.  In 
Dowd's  own  patient  death  occurred  2}^  months  after  operation  from 
metastases  to  the  liver;  and  this  occurrence  was  noted  in  two  other 
patients  who  were  not  operated  on.  Many  cases  of  hemangeioma  are 
cystic  and  hence  are  recorded  with  cysts  rather  than  with  tumors  of 
the  spleen.  The  lesion  probably  is  developmental  in  origin,  as  with 
the  angeiomas  in  other  parts  of  the  body. 

Tuberculosis  or  the  Spleen 

Usually  this  is  a  secondary  involvement,  though  a  few  cases  of 
apparently  primary  infection  have  been  recorded.  The  spleen  is 
not  much  enlarged.  The  formation  of  a  cold  abscess  is  common. 
Splenectomy  is  the  only  efficient  treatment,  but  seldom  can  be  done 
if  the  disease  is  so  far  advanced  as  to  make  the  diagnosis  reasonably 
certain  before  the  abdomen  is  opened.  In  our  first  edition  we  men- 
tioned 15  splenectomies  for  tuberculosis,  with  3  deaths  (20  per  cent.). 


736  SURGERY    OF    THE    SPLEEN 


Syphilis  of  the  Spleen 


Though  the  development  of  the  clinical  picture  of  splenic  anemia  in 
patients  with  syphilis,  and  the  fact  that  the  syphilis  appeared  to  be 
the  cause  of  their  symptoms,  had  been  recognized  by  Marchand  (1903), 
Osier  (1914),  Giffin  (1916),  and  others,  it  remained  for  Norris,  Symmers 
and  Shapiro  (1917)  to  claim  that  all  cases  of  splenic  anemia  were 
syphihtic  in  origin.  Most  authorities,  however,  have  not  been  willing 
to  accept  their  view;  but  while  recognizing  that  in  many  cases  of 
syphilis  of  the  spleen  the  clinical  picture  of  splenic  anemia  may  occur, 
nevertheless  teach  that  other  conditions  (some  known  and  some  un- 
known) may  also  produce  the  same  clinical  picture. 

Syphilis,  both  in  the  congenital  and  the  acquired  form,  frequently 
afifects  the  spleen;  producing  a  diffuse  inflammatory  overgrowth  of 
connective  tissue  with  splenomegaly.  In  the  congenital  cases  there 
results  a  condition  resembling  von  Jaksch's  disease;  and  in  the  later 
stages  of  the  acquired  disease  the  splenomegaly  may  be  independent 
of  cirrhosis  of  the  Hver,  thus  resembling  the  first  stage  of  Banti's  disease. 

When  constitutional  treatment  proves  ineiiective  in  relieving  the 
accompanying  anemia,  the  spleen  may  be  removed,  and  in  cases  where 
this  has  been  done  the  improvement  in  the  patient's  condition  has  been 
immediate  and  striking.  In  Hartwell's  patient  (1913)  the  hemoglobin 
rose  in  two  weeks  from  25  to  80  per  cent. 

Abscess  of  the  Spleen 

Abscess  of  the  spleen,  or  acute  suppurative  splenitis,  may  occur 
in  the  course  of  pyemia  from  any  cause.  In  malignant  endocar- 
ditis, infective  emboK  lodging  in  the  spleen  give  rise  to  abscesses, 
which  are  usually  multiple  and  small.  Infection  of  infarcts  the  result 
of  thrombosis  of  branches  of  the  splenic  artery  gives  rise  to  abscesses 
which  may  be  of  sufficient  size  to  occasion  definite  physical  signs. 
Cases  of  abscess  of  the  spleen  that  are  amenable  to  surgical  treatment 
usually  have  been  preceded  by  some  acute  infectious  fever.  Malaria, 
typhoid,  dysentery,  influenza,  dengue,  and  relapsing  fever  have  been 
reported  as  predisposing  causes.  Typhoid  fever  and  malaria  are  the 
most  frequent  infections  preceding  the  development  of  splenic  abscess. 
The  infecting  agent  in  general  infections  varies  with  the  original  cause 
but  in  those  cases  where  the  spleen  is  the  only  seat  of  disease  the  colon 
bacillus  is  the  organism  most  often  found,  although  staphylococci  are 
occasionally  observed,  and  it  is  probable  that  the  typhoid  bacillus  alone 
is  capable  of  causing  suppuration.     The  majority  of  reports  do  not 


ABSCESS  •  737 

include  bacterial  findings.  Occasionally  the  spleen  may  be  involved  in 
an  abscess  caused  by  extension  from  a  neighboring  focus  of  infec- 
tion, such  as  empyema,  subphrenic  abscess,  perforated  gastric  ulcer, 
perinephric  abscess,  etc.  Hematomas  and  cysts  (simple  or  parasitic) 
may  become  infected  with  resulting  abscess  formation.  Neugebauer 
(1909)  has  reported  a  case  following  appendicitis. 

Pathology. — Pyemic  abscesses  are  multiple  and  small  and  have 
no  distinctive  characteristics.  Those  the  result  of  infection  of  an 
infarct  usually  are  single  and  they  always  extend  to  the  periphery. 
The  majority  of  abscesses  amenable  to  surgical  treatment  (this  includes 
particularly  those  resulting  from  infectious  diseases)  are  single  and  of 
large  size.  When  they  reach  the  surface  of  the  spleen  they  excite 
perisplenitis  resulting  in  the  formation  of  adhesions  to  surrounding 
structures.  The  spleen  always  is  enlarged,  due  partly  to  the  presence 
of  the  abscess  and  partly  to  the  inflammatory  reaction  it  sets  up.  In 
deep-seated  abscesses  the  enlargement  is  uniform,  but  when  they  extend 
to  the  periphery  the  swelling  is  localized,  except  in  the  very  largest 
abscesses  with  destruction  of  the  whole  splenic  pulp.  The  abscess 
cavity  contains  pus  cells,  broken  down  blood  and  splenic  pulp.  These 
sequestra  of  splenic  tissue  have  been  particularly  studied  by  Kiittner 
(1907)  who  found  them  noted  in  43  (37  per  cent.)  of  116  cases  of 
abscess  of  the  spleen  which  he  collected.  The  wall  of  the  abscess  is 
formed  by  necrotic  splenic  tissue  surrounded  by  an  area  of  inflammatory 
reaction.  Occasionally  the  reaction  is  sufficient  to  isolate  and  com- 
pletely wall  off  small  abscesses  so  that  the  contents  eventually  become 
inspissated  and  the  area  of  infection  becomes  quiescent.  Infiltration 
of  the  abscess  wall  with  lime  salts  may  occur,  and  in  some  cases  over- 
growth of  connective  tissue  with  absorption  of  the  abscess  has  resulted, 
leaving  a  small  depressed  scar  to  mark  the  site  of  the  original  lesion. 

An  infected  hematoma  or  cyst  has  its  own  pathological  anatomy, 
to  which  is  added  that  peculiar  to  abscess  formation. 

S5miptoms. — Pain  in  the  left  hypochondrium  is  the  first  and  most 
constant  symptom.  It  varies  in  character  from  a  dull  ache  to  severe 
paroxysms  of  extreme  intensity.  Fever,  chills  and  sweats  are  fairly 
constant  accompaniments,  but  their  significance  may  be  masked 
by  the  original  disease,  as  when  an  abscess  develops  in  the  course  of 
molaria.  Occurring  in  pyemia,  infection  of  the  spleen  is  indicated  by 
acute  pain  in  the  splenic  region  and  aggravation  of  the  symptoms  of 
infection,  with  the  occurrence  of  chills,  fever  and  sweats.  Quite  often 
an  abscess  develops  gradually,  with  obscure  symptoms,  and  compara- 
tively little  pain  and  fever. 


738  SURGERY    OF    THE    SPLEEN 

Perforation  of  a  splenic  abscess  causes  symptoms  that  vary  with 
the  site  of  the  rupture.  General  peritonitis  results  from  perforation 
into  the  peritoneal  cavity,  although  this  usually  is  prevented  by 
the  presence  of  adhesions.  \'omiting  of  pus  and  blood  follows  per- 
foration into  the  stomach,  empj-ema  perforation  through  the  dia- 
phragm, and  the  passage  of  blood  and  pus  by  rectum  a  perforation 
into  the  colon.  Subphrenic  abscess  due  to  disease  of  the  spleen  usually 
is  located  in  the  lesser  peritoneal  cavity.  Among  forty-four  cases  of 
suppuration  in  the  lesser  peritoneal  cavity,  tabulated  by  Michel  and 
Gross  (1904),  seven  were  due  to  disease  of  the  spleen. 

The  general  systemic  disturbances  resulting  from  splenic  abscess 
are  those  of  suppuration  anywhere,  and  their  severity  varies  in 
indi\'idual  cases.  Hectic  fever,  leukocytosis,  secondary  anemia, 
gastro-intestinal  disturbances,  anorexia,  loss  of  weight,  etc.,  occur; 
but  as  these  may  be  present  in  any  form  of  infection  they  have  no 
locaUzing  value. 

Physical  Signs. — The  physical  signs  are  those  of  enlargement 
of  the  spleen,  with  tenderness  and  rigidity  more  or  less  localized 
when  the  abscess  approaches  the  surface.  A  circumscribed  promi- 
nence may  be  seen  and  felt  in  moderate-sized  abscesses,  but  when 
very  large  the  abscess  occupies  so  much  of  the  substance  of  the  spleen 
that  surface  localization  does  not  occur.  If  the  tenderness  is  not 
too  great,  fluctuation  may  be  obtained  in  certain  cases;  in  others 
the  tumor  is  soft  and  doughy  in  consistence,  with  irregular  indurated 
edges;  and  in  still  others  no  area  of  softening  can  be  made  out.  A 
friction  rub  may  be  heard  sometimes  when  perisplenitis  is  present. 

An  abscess  which  develops  toward  the  deeper  surfaces  of  the 
spleen  will  cause  no  demonstrable  localizing  physical  signs,  except 
enlargement  of  the  spleen. 

Diagnosis. — Pain  over  the  spleen  is  by  no  means  pathognomonic 
of  abscess  as  it  occurs  also  in  perisplenitis,  embohsm,  cysts,  enlarge- 
ments in  some  acute  fevers,  etc.  Leukocytosis  is  not  a  constant 
factor,  both  the  actual  and  differential  count  being  normal  in  many 
cases.  Definite  fluctuation  is  infrequent.  There  are,  therefore, 
always  certain  cases  with  such  obscure  histories,  symptoms  and 
physical  signs  that  diagnosis  before  operation  is  difficult  or  impossible. 

Exploratory  puncture  never  should  be  undertaken  because  of 
the  danger  of  peritonitis. 

Frank  cases  of  splenic  abscess  present  fewer  difficulties.  Pain 
and  tenderness  over  an  enlarged  spleen  during  or  following  some 
infectious  fever,  accompamed  by  chills,  fever  and  sweats  and  poly- 


SPLENIC   ANEMIA  739 

morphonuclear  leukocytosis,  indicate  the  probable  presence  of  sup- 
purative splenitis.  If,  in  addition,  a  localized  fluctuating  swelling 
develops  the  diagnosis  is  certain.  In  those  cases  in  which  neither  a 
local  softening  nor  diffuse  fluctuation  is  demonstrable,  rapid  and 
progressive  enlargement  of  the  spleen  is  a  valuable  sign,  and  when 
taken  in  conjunction  with  a  history  indicating  infection,  is  very  char- 
acteristic. 

Careful  attention  to  the  previous  history,  the  symptoms  and  course 
of  the  illness,  and  the  physical  signs  indicate  the  correct  diagnosis 
in  a  majority  of  cases,  in  fact  in  all  but  those  whose  obscurity  renders 
accurate  diagnosis  impossible.  At  the  onset,  the  condition  frequently 
is  mistaken  for  a  relapse  of  the  original  illness  (malaria,  typhoid  fever, 
influenza,  etc.). 

Abscesses  that  do  not  cause  palpable  enlargement  are  of  no  surgical 
significance.  Very  large  splenic  abscesses  have  to  be  differentiated 
particularly  from  perinephric  abscess,  and  from  pyo-  and  hydrone- 
phrosis. 

Prognosis. — In  abscesses  of  embolic  origin  the  prognosis  is  that 
of  the  original  condition,  as  a  rule  very  unfavorable.  Those  amenable 
to  surgical  treatment  are  not  the  result  of  pyemia  and  give  a  much 
more  favorable  outlook.  A  number  of  recoveries  following  operation 
are  reported.  Recovery  has  occasionally  followed  spontaneous  rupture 
and  discharge,  but  the  abscess  usually  reforms  if  the  patient  survives 
the  rupture.  In  single  abscesses  arising  from  local  conditions  the 
prognosis  depends  on  early  recognition  and  prompt  operation.  Under 
these  circumstances  a  large  percentage  of  recoveries  may  be  expected. 

Treatment. — Incision  and  drainage  is  the  operation  usually  under- 
taken and  the  one  most  generally  applicable.  Under  certain 
circumstances  splenectomy  may  be  preferable,  as  for  instance,  when 
the  abscess  recurs  after  drainage.  As  a  rule  perisplenic  adhesions 
render  splenectomy  impossible. 

Johnston  in  1908  collected  nine  splenectomies  for  abscess  with 
eight  recoveries.  Perkins,  in  1907,  wrote  that  splenectomy  had 
been  performed  successfully  ten  times  for  splenic  abscess.  All  re- 
ported cases  to  which  we  have  reference  since  1908  have  been  treated 
by  incision  and  drainage.  Balfour  (191 7)  refers  to  27  operations 
for  splenic  abscess  with  4  deaths  (15  per  cent.). 

Banti's  Disease  or  Splenic  Anemia 

This  group  includes  splenic  pseudoleukemia,  primary  spleno- 
megaly with  anemia,  splenic  lymphadenoma,  idiopathic  or  cryptogenic 


740  SURGERY  OF  THE  SPLEEN' 

splenomegaly,  splenomegalic  cirrhosis  of  the  liver  and  primitive 
endothelioma  of  Gaucher,  although  many  investigators  class  the 
latter  disease  as  a  new  growth.  With  this  exception  it  is  generally 
considered  that  all  the  other  conditions  represent  different  names 
for,  or  various  stages  of  the  same  disease,  but  a  great  deal  of  confusion 
still  exists  in  regard  to  the  classilication  of  diseases  characterized  by 
splenomegaly  and  anemia.  From  a  surgical  standpoint  the  con- 
ditions here  included  as  stages  of  or  dift'erent  names  for  Banti's  disease 
have  a  strong  reason  to  be  grouped  together,  apart  from  their  symp- 
toms and  pathology,  as  they  are  all,  except  splenomegalic  cirrhosis, 
greatly  improved  if  not  permanently  cured  by  splenectomy.  Cirrhosis 
is  the  last  stage  of  Banti's  disease  and  when  it  appears  the  time  has 
passed  when  splenectomy  could  have  had  any  effect  on  the  progress 
of  the  disease.  The  relation  of  syphilis  to  Banti's  disease  was  men- 
tioned at  p.  736. 

Banti's  disease  was  tirst  described  by  him  in  18S2,  and  is  character- 
ized by  great  chronicity  and  three  definite  clinical  and  pathological 
stages: 

1.  Simple  enlargement  of  the  spleen. 

2.  Enlargement  with  secondary  anemia. 

3.  Cirrhosis  of  the  liver  with  splenomegaly. 

Etiology. — Our  knowledge  of  the  etiology  of  Banti's  disease  does 
not  rest  on  a  firm  basis.  IMany  theories  have  been  advanced  but 
no  definite  causative  agent  is  known. 

Banti's  own  belief  is  that  the  disease  is  due  to  an  unknown  infective 
agent  setting  up  changes  of  a  non-inflammatory  character.  This 
agent  is  carried  by  the  blood  to  the  spleen  and  causes  degeneration 
of  the  splenic  pulp  and  follicles  and  hyperplasia  of  the  reticulum; 
the  latter  is  the  more  conspicuous  feature  and  results  in  the  develop- 
ment of  the  fibro-adenomatous  appearance  so  commonly  seen;  the 
morbific  agent,  according  to  Severino  (191 1),  is  then  carried  away 
from  the  spleen  in  the  splenic  vein,  which  at  autopsy  always  is  found 
sclerosed.'  Two  theories  as  to  the  origin  of  this  toxin  are  maintained; 
according  to  one  theory  this  toxin  is  supposed  to  be  elaborated  in  the 
spleen,  which  is  recognized  as  the  seat  of  primary  disease;  the  other 
theory  is  that  the  toxin  is  formed  as  the  result  of  disordered  metabo- 
lism elsewhere  in  the  body.  It  is  not  improbable  that  toxins  may 
be  formed  in  both  ways.  Banti  favors  the  second  theory  of  the 
origin  of  the  toxin.  Osier  suggested  an  autointoxication  of  gastro- 
intestinal origin  as  the  starting-point  of  the  disease.  Rolleston 
'  Warthin's  views  on  this  subject  are  mentioned  at  p.  743. 


SPLENIC   ANEMIA  74I 

believed  that  the  spleen  is  the  site  of  a  chronic  infective  or  toxic 
process  which  occasions  the  pathological  changes  observed  there  and 
which  subsequently  inhibits  blood  formation  and  causes  secondary- 
anemia. 

Discussing  splenic  anemia,  Sutherland  and  Burghard  (1910) 
advanced  the  theory  that  this  condition  is  a  functional  disturbance 
of  the  spleen  and  not  necessarily  an  actual  disease.  They  explain 
the  origin  of  the  signs  and  symptoms  as  follows:  Normally  the 
endothelial  cells  of  the  spleen  ingest  old  red  blood  cells.  Loss  of 
vasomotor  control  of  the  splenic  artery,  due  to  disease  of  the  visceral 
sympathetic  ganglia  (Barr),  causes  overfilling  of  the  spleen,  and  this 
results  in  hyperplasia  and  increased  functional  activity.  In  con- 
sequence of  this  increased  activity  the  endothelial  cells  destroy  both 
diseased  and  healthy  red  blood  cells  (Harris  and  Herzog).  The  quick 
regeneration  of  erythrocytes  and  hemoglobin  after  splenectomy 
indicates  hemolysis  and  not  diminished  blood  formation  as  the  cause 
of  the  anemia.  The  rapid  rise  in  the  number  of  red  blood  cells  suggests 
that  the  blood-forming  organs,  which  have  been  working  at  high 
pressure  to  overcome  the  excessive  destruction  caused  by  the  spleen, 
are  able  to  regenerate  the  blood  very  rapidly  after  the  spleen  has 
been  extirpated. 

The  bacteriology  of  Banti's  disease  is  negative.  Animal  experi- 
ments and  careful  study  of  operative  and  postmortem  specimens 
have  emphasized  the  fact  that,  if  it  is  an  infective  disease,  the  causative 
agent  is  still  unknown. 

There  seems  to  be  no  necessary  connection  between  the  previous 
medical  history  and  the  occurrence  of  Banti's  disease;  the  relation 
of  syphilis  to  Banti's  disease  has  already  been  discussed  (p.  736); 
but  malaria,  other  infectious  diseases  and  alcoholism  have  not  been 
proved  to  have  etiological  significance.  Nor  is  there  any  evidence 
to  show  a  family  predisposition  for  the  disease  except  in  the  case  of 
the  primary  endothelioma  of  Gaucher.  Several  observers  of  the 
latter  disease  have  reported  a  family  incidence  with  a  tendency  to 
appear  in  several  members  of  the  same  generation. 

It  seems  safest  to  conclude  that  Banti's  disease  may  be  due  to  a 
number  of  different  factors;  but  it  remains  for  the  future  to  identify 
these  more  definitely  before  any  etiological  classification  can  be  made 
of  the  diseases  now  grouped  together  for  practical  purposes  under  the 
same  name  (Banti's  disease). 

Age. — Cases  are  reported  at  ages  from  six  to  seventy-two  years  but 
the  great  majority  occur  between  twenty  and  forty-five  years.     The 


742  SURGERY  OF  THE  SPLEEN 

age  of  Banti's  fifty  patients  ranged  from  twelve  to  fifty-five  years, 
two  occurring  before  the  age  of  fifteen  years,  seventeen  between 
fifteen  and  twenty-five  years,  fifteen  between  twenty-five  and  thirty- 
five  years,  eleven  between  thirty-five  and  forty-five  years,  and  five 
between  forty-five  and  fifty-five  years.  The  age  of  Osier's  fifteen 
patients  ranged  from  twenty  to  fifty-eight  years;  that  of  West's  twenty 
patients  from  nine  to  seventy-two  years.  Sutherland  and  Burghard 
report  a  splenectomy  for  splenic  anemia  in  a  child  six  years  old.  It 
is  probable  that  many  cases  begin  in  childhood  and  on  account  of  the 
chronic  course  of  the  disease  the  patient  does  not  come  under  treatment 
for  some  years.  The  senior  author  has  recently  operated  on  a  female 
child  twenty-two  months  old,  with  recovery.  The  differential  diagno- 
sis of  the  splenomegalies  of  childhood  offers  unusual  difficulties  on 
account  of  their  number,  variety  and  obscure  etiology. 

Sex. — The  first  series  of  cases  of  Banti's  disease  published  showed 
a  great  preponderance  of  males:  thirteen  of  Osier's  fifteen,  nineteen 
of  West's  twenty-four,  and  seven  of  Lyon's  eight  cases.  More  recent 
reports  do  not  sustain  these  figures;  thirty-two  of  Banti's  fifty  patients 
were  females,  and  of  Simonds's  collected  forty-eight  cases,  twenty- 
five  were  females  and  twenty-three  males.  Torrance  collected  thirty- 
six  splenectomies  for  Banti's  disease;  seventeen  of  the  patients  were 
females,  fifteen  were  males.  In  four  the  sex  was  not  mentioned. 
Practically,  therefore,  both  sexes  are  about  equally  affected. 

No  race  or  country  is  particularly  associated  with  the  occurrence 
of  the  disease. 

Pathology. — The  first  changes  occur  in  the  spleen,  and  these 
attain  their  permanent  character  before  any  other  pathological  altera- 
tions appear.  Then  secondary  anemia  develops  and  finally  the 
changes  in  the  liver  and  portal  system  complete  the  morbid  anatomy 
of  the  disease. 

Spleen. — The  spleen  enlarges  steadily  but  retains  its  normal  shape 
and  appearance.  The  average  weight  is  from  1500  to  1750  grams 
but  enormous  hypertrophy  is  reported  at  times.  The  largest  spleen 
in  Simonds's  collected  cases  weighed  4500  grams,  and  in  Bovaird's 
case  (1900)  of  endothelioma  the  spleen  weighed  6250  grams. 

Very  commonly  there  are  a  large  number  of  perisplenic  adhe- 
sions, and  these  may  give  great  trouble  at  operation,  sometimes 
rendering  splenectomy  impossible. 

The  capsule  and  fibrous  tissue  of  the  trabeculae  undergo  con- 
siderable hjrpertrophy,  but  the  most  marked  change  is  hyperplasia 
of  the  reticular  fibres  without   anv  marked   change  in   the  cellular 


SPLENIC    ANEMIA  743 

elements.  The  Malpighian  corpuscles  are  overgrown  with  connective 
tissue  and  atrophied,  and  in  some  places  have  completely  disappeared. 
In  addition  the  whole  spleen  shows  more  or  less  passive  hyperemia. 
There  is  also  in  every  case  some  proliferation  of  the  endothelium  of 
the  sinuses.  Very  often  normal  areas  of  splenic  tissue  with  function- 
ally active  Malpighian  corpuscles  remain  scattered  throughout  the 
substance  of  the  spleen. 

The  amount  of  endothelial  proliferation  varies  and  may  be  so 
great  as  to  cause  the  characteristic  changes  known  as  primitive  endothe- 
lioma of  the  type  of  Gaucher  (1882).  In  these  cases  the  spleen  as  a  rule 
is  uniformly  enlarged,  but  in  Stengel's  case  a  nodular  growth  was 
present.  Microscopic  examination  reveals  hyperplasia  of  the  endothe- 
lium occurring  in  large  masses.  In  addition  there  are  areas  of  necrosis 
and  hemorrhage  and  overgrowth  of  the  reticular  connective  tissue. 
The  liver,  lymph-nodes  and  bone  marrow  also  show  these  endothelial 
accumulations.  The  characteristic  large  vesicular  cells  with  small 
eccentric  nuclei  block  the  sinuses  of  the  spleen  and  lymph  nodes,  or 
are  crowded  about  the  liver  lobules.  The  appearance  of  the  spleen 
is  strongly  suggestive  of  a  new  growth;  but  the  long  duration,  the 
uniform  distribution  of  the  areas  of  endothelial  proliferation  and  the 
cure  of  the  condition  by  splenectomy  are  strong  arguments  against 
malignancy.  Pathologically,  primitive  endothelioma  is  a  distinct 
and  definite  form  of  splenomegaly  but  clinically  it  has  the  characteris- 
tics of  splenic  anemia.  The  disease  begins  before  the  thirteenth  year 
of  life;  the  child  slowly  develops  a  tendency  to  submucous  and  sub- 
cuticular hemorrhages;  and  extreme  enlargement  of  the  spleen  occurs. 
Enlargement  of  the  liver  is  secondary  but  may  be  of  considerable 
proportions.  There  is  a  brownish  yellow  discoloration  of  the  skin, 
and  often  a  peculiar  yellowish  wedgeshaped  thickening  of  the  con- 
junctiva. According  to  Pearce,  Krumbhaar  and  Frazier  (1918)  there 
are  only  17  authentic  cases  on  record.  Splenectomy  was  adopted  in  10 
cases,  with  3  deaths. 

Splenic  Vein. — There  is  always  some  chronic  sclerosing  endo- 
phlebitis  of  the  splenic  veins  and  in  some  cases  it  is  excessive,  with 
calcification  and  stenosis.  The  portal  vein  may  also  be  affected. 
Warthin  (1910)  claimed  that  such  changes  were  the  primary  lesion, 
resulting  from  any  cause  of  inflammation,  and  that  the  changes  in  the 
spleen  were  merely  secondary  to  the  passive  congestion  thus  induced. 
This  was  the  view  previously  taken  by  Hill  (1909)  and  others;  but  it  is 
not  generally  accepted. 

Liver. — There  is  no  change  in  the  liver  until  late  in  the  second 


744  SURGERY    OF    THE    SPLEEN 

Stage  of  the  disease.  From  this  time  on  the  changes  cannot  be  distin- 
guished from  those  of  Laennec's  atrophic  cirrhosis. 

Symptoms  and  Physical  Signs. — Banti's  disease  runs  an  extremely 
chronic  course  of  from  five  to  twenty-five  years. 

First  Stage. — -This  is  characterized  by  its  insidious  onset  and  long 
duration.  There  is  gradual  progressive  and  painless  enlargement  of  the 
spleen,  which  may  be  accompanied  by  a  sense  of  weight  and  discomfort 
in  the  left  hypochondrium.  The  increase  in  size  of  the  spleen  continues 
until  the  lower  pole  is  on  a  level  with  or  below  the  umbilicus,  but  when 
the  pelvic  brim  is  reached  growth  ceases.  The  splenic  tumor  in  these 
cases  is  as  big  as  any  except  the  largest  of  the  leukemic  spleens.  There 
is  no  connection  between  the  size  of  the  spleen  and  the  occurrence 
or  severity  of  the  symptoms.  Splenomegaly  is  present  for  three 
to  five  years  or  longer  before  the  onset  of  the  symptoms  of  anemia 
which  mark  the  beginning  of  the  second  stage. 

Second  Stage. — The  early  symptoms  of  this  stage  are  those  of 
simple  anemia,  pallor,  weakness,  dyspnea  and  palpitation.  The  grade 
of  the  anemia  has  no  relation  to  the  severity  of  the  disease.  With  the 
development  of  these  symptoms  the  blood  usually  shows  changes  of 
chlorotic  type — diminution  of  red  blood  cells  and  hemoglobin,  with  a 
low  color  index.  The  hemoglobin  may  be  diminished  to  50  or  even  40 
per  cent.  In  addition  there  is  also  leukopenia  with  relative  lympho- 
cytosis; the  total  count  may  fall  to  1000-1500  per  cubic  millimetre. 
Leukopenia  is  very  characteristic  of  splenic  anemia,  but  in  common 
with  diminution  in  the  red  blood  cells  and  hemoglobin  is  not  neces.- 
sarily  present  in  all  cases.  These  changes  may  be  very  slight  or  even 
completely  absent  even  when  the  symptoms  of  anemia  are  well  devel- 
oped. Later  in  the  disease  the  blood  picture  may  be  profoundly 
modified  by  hemorrhages. 

Following  the  appearance  of  anemia,  changes  in  the  amount 
and  quality  of  the  urine  occur.  Banti  associates  the  onset  of  the  second 
stage  with  the  appearance  of  urinary  changes.  The  amount  of  urine 
diminishes  to  1000  c.c.  or  less  in  twenty-four  hours,  and  it  contains 
urobilin  and  albumen  intermittently. 

The  liver  begins  to  enlarge,  until  it  is  readily  palpable  three  or  four 
fingers'  breadths  below  the  costal  margin  in  the  right  nipple  line.  It  is 
smooth  and  painless.     There  is  no  ascites  or  jaundice. 

Gastro-intestinal  hemorrhages,  particularly  hematemesis.  may  occur 
before  the  onset  of  cirrhosis.  Forty  per  cent,  of  the  blood  from 
the  stomach  reaches  the  portal  system  through  the  vasa  brevia  and 
splenic  vein,  and  hematemesis  is  the  mechanical  result  of  congestion  of 


SPLENIC    ANEMIA  745 

the  splenic  vein.  Other  hemorrhages,  subcutaneous,  from  the  nose  and 
gums,  hematuria  and  melena  may  also  occur.  Digestive  disturbances 
and  diarrhea  occasionally  are  observed. 

The  skin  and  conjunctiva  may  develop  a  grayish-yellow  color, 
but  actual  pigmentation  or  jaundice  does  not  occur  in  this  stage. 

With  the  approach  of  the  third  stage  the  liver  diminishes  in  size. 
The  second  stage  lasts  from  eighteen  months  to  several  years. 

Third  Stage. — The  onset  of  the  third  stage  is  characterized  by 
the  development  of  ascites.  This  does  not  necessarily  mean  the 
presence  of  cirrhosis  of  the  liver,  since  ascites  frequently  is  seen  before 
cirrhosis  is  demonstrable,  as  is  shown  by  several  operations  and 
autopsy  reports.  Anemia  and  enlargement  of  the  spleen  are  the 
causative  factors  under  these  circumstances.  The  ascitic  fluid  has 
all  the  appearances  of  a  transudate.  It  reforms  rapidly  after 
paracentesis. 

The  liver  continues  to  diminish  in  size  and  well-marked  cirrhosis 
develops.  The  gastro-intestinal  hemorrhages  are  aggravated.  The 
urine  is  still  further  diminished  and  contains  urobiUn  and  at  times 
bilirubin.  The  skin  develops  a  certain  amount  of  pigmentation  in  a 
few  cases  and  late  in  the  disease  actual  jaundice  may  occur. 

Diagnosis. — The  diagnosis  of  Banti's  disease  or  splenic  anemia  in 
the  early  stages,  before  the  appearance  of  the  anemia,  is  impossible. 
Whatever  the  subsequent  developments,  at  this  stage  the  case  is  one  of 
"idiopathic"  splenomegaly.  Even  after  the  appearance  of  anemia 
the  differential  diagnosis  presents  many  difficulties.  Fortunately  the 
technique  of  splenectomy  is  so  simple,  and  within  recent  years  the 
indications  have  be'en  so  extended  that  a  great  many  of  the  conditions 
that  might  be  confused  with  splenic  anemia  are  now  subjected  to  the 
same  treatment,  splenectomy. 

The  diagnosis,  [however,  often  may  be  made  with  reasonable  cer- 
tainty. The  splenic  enlargement  first  must  be  distinguished  from 
tumors  of  other  organs.  This  subject  was  considered  at  page  723. 
Certain  other  diseases  must  then  be  excluded.  The  most  important 
of  these  are  discussed  below. 

As  cirrhosis  of  the  liver  is  the  terminal  stage  of  Banti's  disease,  it  is 
possible,  in  the  later  stages  of  the  latter  aft'ection,  that  doubt  will  arise 
as  to  the  causation  of  the  splenomegaly.  If  symptoms  characteristic  of 
hepatic  cirrhosis,  such  as  hematemesis,  ascites,  jaundice  ancl  decrease  in 
the  size  of  the  liver,  appear  after  the  splenic  enlargement  has  existed  for 
some  time,  clinically  the  case  is  Banti's  disease  in  the  terminal  stage; 
although  it  must  be  remembered  that  these  symptoms  do  not  neces- 


746  SURGERY   OF   THE    SPLEEN 

sarily  mean  that  hepatic  cirrhosis  exists,  as  they  may  precede  its 
development.  Enlargement  of  the  spleen  occurring  at  the  same  time 
or  after  the  changes  in  the  Hver  and  the  onset  of  symptoms,  indicates 
that  the  true  condition  is  cirrhosis  of  the  liver  rather  than  Banti's 
disease.  The  history  and  physical  signs  may  enable  one  to  determine 
the  form  of  cirrhosis  which  is  present. 

That  this  degree  of  simplicity  in  reaching  a  diagnosis  is  not  always 
observed,  is  shown  by  the  confusion  that  still  exists  in  the  classihcation 
of  these  cases.  The  three  forms  of  hepatic  cirrhosis  most  likely  to  be 
mistaken  for  splenic  anemia  are  the  syphilitic,  the  alcoholic  and  the 
hypertrophic  of  Hanot. 

In  Syphilitic  Cirrhosis  of  the  liver  the  previous  history,  the  Wasser- 
mann  reaction,  and  the  result  of  treatment  are  the  main  points  on  which 
reliance  may  be  placed  in  reaching  a  diagnosis.  Moreover,  the  en- 
largement of  the  Kver  due  to  s>'philis  is  irregular.  Leukopenia  is 
absent  and  in  some  cases  there  is  a  persistent  but  moderate  leukocyto- 
sis. It  must  be  remembered  that  a  positive  Wassermann  reaction  is 
not  necessarily  diagnostic,  as  there  is  no  reason  to  suppose  that  a  man 
with  Banti's  disease  might  not  have  had  syphilis  previously.  Nor  is  the 
size  of  the  spleen  a  sign  to  be  depended  upon,  as  this  varies  from  mod- 
erate to  great  enlargement  just  as  in  Banti's  disease.  The  anemia  of 
syphilitic  cirrhosis  may  be  very  severe.  Extreme  anemia  of  undeter- 
mined origin  always  suggests  syphiUs. 

In  Alcoholic  Cirrhosis,  the  small  Hver,  big  spleen  and  anemia 
suggest  Banti's  disease  with  recurring  hemorrhages. 

The  age  of  onset,  alcohoHc  history,  early  appearance  of  symp- 
toms of  cirrhosis  and  the  late  development  of  splenomegaly  wiU  serve 
for  differentiation  from  all  except  the  most  rapidly  developing  cases  of 
Banti's  disease. 

In  the  Hypertrophic  Cirrhosis  of  Hanot,  the  great  enlargement  of 
the  liver  and  the  marked  jaundice  usually  are  sufficient  to  indicate  that 
the  enlargement  of  the  spleen  is  secondary,  even  if  the  time  of  the  occur- 
rence of  splenic  enlargement  in  relation  to  hepatic  enlargement  is  not 
known. 

The  question  of  splenectomy  in  the  cirrhoses  of  the  liver  has  already 
been  discussed  in  connection  with  the  latter  subject  (p.  557). 

Hemachromatosis. — This  is  a  rare  condition  of  biliary  and  splenic 
enlargement*associated  with  hemolysis  of  unknown  origin.  Pigmenta- 
tion of  the  skin  and  internal  organs  results  from  the  deposit  of  an 
iron  containing  pigment.  Hepatic  and  splenic  enlargement  occur  syn- 
chronously. 


SPLENIC   ANEMIA  747 

Pernicious  Anemia. — Cases  of  pernicious  anemia  with  great  enlarge- 
ment of  the  spleen  are  not  very  uncommon  and  in  certain  stages  readily 
may  be  mistaken  for  splenic  anemia.  If  the  anemia  is  extreme,  the 
color  index  high,  and  if  nucleated  red  blood  cells  and  poikilocytes 
are  present,  the  case  is  much  more  likely  to  be  one  of  pernicious  anemia 
than  of  Banti's  disease,  even  though  the  spleen  is  enlarged  to  the  pelvic 
brim.  Even  if  the  changes  in  the  blood  characteristic  of  pernicious 
anemia  are  absent,  the  presence  of  extreme  anemia  is  against  Banti's 
disease  unless  there  has  been  a  recent  severe  hemorrhage  to  account 
for  it.  Even  in  the  late  stages  of  Banti's  disease  it  is  uncommon  for 
the  proportion  of  hemoglobin  to  fall  below  40  per  cent,  unless  there 
has  been  recently  a  severe  hemorrhage.  Morris  Lewis  reported  (1908) 
a  case  of  Banti's  disease  in  which  the  hemoglobin  was  90  per  cent,  a 
short  time  before  the  onset  of  hemorrhage  and  18  per  cent,  a  few 
days  later.  The  history  and  blood  picture  usually  serve  to  differenti- 
ate the  two  conditions,  and  confusion  will  be  less  apt  to  occur  if 
it  is  borne  in  mind  that  a  tremendously  enlarged  spleen  does  not 
necessarily  rule  out  pernicious  anemia. 

Hodgkin's  Disease. — A  splenic  form  of  Hodgkin's  disease,  charac- 
terized by  anemia,  enlarged  spleen  with  lymph-adenomatous  masses 
but  without  enlargement  of  the  superficial  lymph-nodes,  has  been 
described  by  some.  Ijut  it  is  very  questionable  whether  such  a  condition 
exists. 

Malarial  Hypertrophy. — Severe  secondary  anemia  with  enlarged 
spleen  as  a  sequel  of  malaria  presents  many  of  the  characteristics 
of  splenic  anemia.  The  previous  history  usually  is  definite  enough  to 
enable  one  to  avoid  a  mistake  in  diagnosis.  If  repeated  blood  examina- 
tion is  negative,  exploratory  splenic  puncture,  as  a  rule,  reveals  the 
malarial  parasite,  but  is  open  to  the  objection  that  it  exposes  the  patient 
to  the  risk  of  severe  hemorrhage.  On  account  of  the  anemia  and  the 
danger  of  rupture  from  slight  degrees  of  traumatism  splenectomy  is 
becoming  increasingly  popular  as  a  treatment  for  "ague  cake"  spleen. 

Leukemia  is  diagnosed  by  the  blood  picture.  During  remissions 
when  the  blood  returns  to  normal,  the  diagnosis  is  difiBcult;  but  observa- 
tion of  the  patient  for  a  short  time  reveals  the  true  condition. 

Syphilis  is  not  often  a  cause  of  symptoms  and  physical  signs  resem- 
bling splenic  anemia.  The  Wassermann  reaction  and  the  result  of 
treatment  in  doubtful  cases  are  sufficient  to  establish  the  diagnosis. 
In  adults  this  splenic  enlargement  usually  but  not  always  is  secondary 
to  syphilitic  affections  of  the  liver,  while  in  children  syphilis  causes 
primary  splenomegaly.     D'Arcy  Power  (1008)  reported  a  successful 


748 


SURGERY    OF    THE    SPLEEN 


case  of  splenectomy  for  simple  hypertrophy,  which  turned  out  to  be 
syphilitic  in  origin.  Hartwell's  successful  case  has  already  been  men- 
tioned (p.  736).  Gumma  of  the  spleen  is  of  pathological  rather  than 
surgical  interest. 

Amyloid  spleen  always  is  secondary  to  causes,  such  as  suppuration, 
tuberculosis,  etc.,  which  are  easily  demonstrable. 

Tumors  and  tuberculosis  of  the  spleen  are  discussed  at  page  735. 
Splenomegaly  in  Childhood. — Except  the  hypertrophy  occurring  in 
acute  infectious  diseases,  enlargement  of  the  spleen  in  infancy  and  early 
childhood  is  a  condition  of  obscure  etiology.  Congenital  syphiHs 
especially,  and  rickets,  disturbances  of  metabolism  and  intestinal 
disorders  of  doubtful  classification  are  all  considered  etiological  factors 
in  this  group.  It  is  very  likely  that  some  are  cases  of  true  splenic 
anemia;  but  on  account  of  the  frequency  of  splenomegaly  in  childhood 
from  other  causes,  and  the  uncertainty  of  the  blood  picture,  such  a 
diagnosis  always  is  doubtful. 

Pseudoleukemia  infanlium  of  \on 
Jaksch  (1889),  which  usually  appears  in 
the  second  year  of  life,  is  characterized 
by  marked  splenomegaly  and  usually  by- 
moderate  enlargement  of  the  liver  (Fig. 
171).  The  red  blood  cells  may  be  re- 
duced to  1,000,000  and  the  hemoglobin 
falls  disproportionately,  giving  a  low 
ciilor  index.  The  blood  shows  normor 
blasts,  poikilocytosis,  leukocytosis 
(15-20,000),  and  relative  increase  in 
lymphocytes.  Krumbhaar  (191 8)  re- 
gards the  disease  not  as  an  independent 
condition,  but  thinks  it  represents  an 
atypical  response  of  the  infantile  hemo- 
poietic system  to  such  diseases  as  leuke- 
mia, pernicious  anemia,  rachitis,  syphilis, 
Banti's  disease,  hemolytic  jaundice,  etc. 
A  history  of  congenital  syphilis  is  present 
in  about  50  per  cent,  of  cases,  and 
is  regarded  by  Xorris,  Symmers  and  Shapiro  (1917)  as  the  cause  of 
the  disease.  Stillman  (1917)  collected  6  cases  of  splenectomy  with  re- 
covery and  relief  of  symptoms,  but  in  most  cases  medical  treatment  gives 
very  good  results,  and  even  in  severe  cases  iron,  arsenic  (arsphcnamin) 
and  mercury  cause  improvement  and  eventual  cure  in  a  certain  pro- 


FiG.  171.--  ^i■  '  •■  '  :-_:!■.  i.f  Un- 
determined Origin  in  a  Child  aged 
sJ^  Years.      (Ashhurst.) 


SPLENIC    ANEMIA 


749 


portion  of  patients.     One  of  the  successful  cases  of  splenectomy  was 
in  a  child  aged  15  months  (Grafif,  1908). 

Prognosis  and  Treatment  of  Banti's  Disease. — Medical  treatment  is 
absolutely  worthless  as  regards  the  cure  or  arrest  of  the  disease.  With 
the  most  skillful  administration  of  drugs  or  other  therapeutic  agents, 
such  as  the  X-rays,  the  course  of  the  disease  is  steadily  toward  a 
fatal  termination.  Splenectomy  is  the  only  form  of  treatment  that 
offers  any  hope  of  permanent  cure.  As  the  operations  and  reported 
cases  multiply  and  as  the  after-results  are  studied,  it  is  becoming 
more  and  more  evident  that  surgery  effects  an  absolute  cure  in  the 
first  stage  of  the  disease  in  every  patient  who  makes  an  operative 
recovery.  In  the  second  stage  the  primary  mortality  is  higher  and  the 
percentage  of  permanent  cures  is  less.  In  the  third  stage  the  disease  is 
too  advanced  to  expect  any  good  results  from  splenectomy,  but  Talma's 
operation  may  be  undertaken  at  this  time  with  moderate  hope  of  success 
in  removal  of  the  symptoms  of  cirrhosis.  One  point  should  be  thoroughly 
understood:  ascites  and  slight  or  transient  jaundice  occurring  in  the 
course  of  Banti's  disease  do  not  absolutely  contraindicate  splenec- 
tomy, because  they  may  occur  before  cirrhosis  of  the  liver  is  present. 
The  latter  is  the  only  contraindication  to  splenectomy,  and  it  is  not  an 
absolute  contraindication.  Banti  reported  ten  operations  on  his  own 
patients  and  twenty  collected  operations  with  the  following  results: 


Splenectomy  for 
Banti's  Disease 


Banti's  Cases 


Operations 


Cures 


Collected  Cases 


Operations 


Cures 


First  period. . 
Second  period 
Third  period. 


2 

16 

2 


From  January  i,  1908,  to  January  i,  1912  there  were  reported 
thirty-seven  operations  for  Banti's  Disease  with  nine  operative  deaths, 
a  mortality  of  24.3  per  cent.  Krumbhaar  (1918)  collected  a  total  of 
183  splenectomies  for  Banti's  disease,  with  28  deaths,  a  mortality 
of  15.4  per  cent.  Five  cases  in  the  hands  of  the  senior  author  have 
all  been  successful.  Mayo  (1919)  reports  from  the  Mayo  Clinic 
61  splenectomies  for  Banti's  diseases  with  7  deaths,  a  mortality  of  11. 7 
per  cent. 

Splenectomy  is  recognized  as  the  only  rational  treatment  for 
Banti's  disease,  and  better  results  are  to  be  expected  in  the  future 


750  SURGERY    OF    THE    SPLEEN 

with  earlier  resort  to  operation.  Splenectomy  should  be  undertaken 
as  soon  as  the  diagnosis  is  made,  and  the  knowledge  that  the  disease 
can  be  cured  by  operation  should  bring  home  to  every  physician  the 
importance  of  early  diagnosis. 

The  success  of  splenectomy  seems  to  indicate  that  the  spleen 
is  closely  associated  with  the  causation  of  the  changes  characteristic 
of  the  second  and  third  stages;  but  its  real  modus  operandi  is  not 
understood.  Mayo  thinks  its  success  depends  chiefly  on  relieving  the 
liver  of  an  overload  by  cutting  off  all  the  blood  normally  delivered 
to  the  liver  through  the  splenic  vein:  this  is  about  one-third  of  the 
total  portal  circulation,  and  in  cases  of  splenomegaly  must  be  a  con- 
siderably larger  proportion.  But  is  it  not  rather  the  concentration  of 
poisons  that  is  reduced  by  splenectomy?  All  the  substances  which 
entered  the  spleen  through  the  splenic  artery  remain  even  after  re- 
moval of  the  spleen,  unless  excreted  elsewhere;  but  after  splenectomy 
they  no  longer  are  delivered  to  the  Uver  in  concentrated  form,  but 
only  through  the  hepatic  artery  and  superior  mesenteric  vein  after 
much  dilution  by  their  circuit  through  the  bod3\ 

Splenocleisis. — Under  this  name  Schiassi  (.1905)  described  an 
operation  for  Banti's  disease  in  which  the  enlarged  spleen  is  not 
removed,  but  is  packed  all  around  with  iodoform  gauze.  This  is 
to  be  allowed  to  remain  for  from  six  to  ten  days,  by  which  time  suffi- 
cient adhesions  will  have  formed  to  ensure  reduction  in  size  of  the 
spleen  by  their  ultimate  contraction.  The  large  veins  formed  in 
this  way  are  supposed  to  divert  the  blood  from  the  spleen  into  the 
abdominal  wall.  Mugnai  adopted  this  method  in  one  case,  but  the 
patient  died  from  internal  hemorrhage  the  next  day. 

Hemolytic  Icterus 

Hemolytic  jaundice  occurs  (i)  as  a  congenital,  familial  disease 
and  (2)  as  an  acquired  disease  of  adult  life.  The  former  was  described 
in  1900  by  Minkowski  as  "congenital  acholuric  icterus;"  and  is  much 
commoner  than  the  acquired  form  of  the  disease  which  is  known  by 
the  names  of  Hayem  (1898)  and  Widal  (1907):  of  159  cases  studied  by 
Krumbhaar  (1918),  104  belonged  to  the  familial  tj'pe  and  only  55  to 
the  acquired.  Chaufifard  (1914)  drew  particular  attention  to  congenital 
syphilis  as  a  cause,  though  one  of  his  patients  acquired  syphilis  in 
adult  hfe  many  years  after  liis  hemolytic  jaundice  first  appeared;^  in 

'The  occurrence  of  infantilism,  dwarfing,  etc.,  in  some  of  these  patients  probably  is 
an  evidence  of  congenital  sj-philis. 


HEMOLYTIC   ICTERUS  .  751 

Other  cases  he  incriminated  tuberculosis,  or  at  least  claims  that  in- 
stances occur  in  those  already  tuberculous.  He  refers  to  those  suffer- 
ing with  the  congenital  form  of  the  disease  as  being  more  icteric  than 
sick,  and  it  is  a  fact  that  many  such  patients  live  for  many  years 
with  very  httle  inconvenience.  Mayo  (1919)  suggests  that  as  the 
spleen  destroys  excessive  numbers  of  erythrocytes  and  thus  inundates 
the  liver  with  blood  pigment,  this  renders  the  bile  viscid,  and  pre- 
disposes to  gallstone  formation  (60  per  cent,  of  his  patients  with 
hemolytic  icterus  have  had  a  complicating  cholelithiasis) ;  while  gall- 
stones, with  the  accompanying  infectious  cholangeitis,  predispose  to  or 
may  actually  produce  the  biliary  cirrhosis  which  often  exists.  It  is  on 
this  account  that  the  disease  is  so  often  confused  with  the  so-called 
Hanot's  biliary  cirrhosis,  a  disease  whose  existence  is  doubted  by 
Mayo  (p.  554). 

The  fundamental  symptoms  are:  (i)  splenomegaly,  (2)  anemia, 
(3)  jaundice.  Patients  come  under  treatment  on  account  of  the 
anemia;  the  large  spleen  may  give  no  trouble  and  often  passes  un- 
noticed; while  the  jaundice,  which  rarely  is  more  than  an  extreme 
sallowness  of  complexion,  is  "acholuric,"  and  is  unattended  by  the 
usual  symptoms  of  obstructive  ("choluric")  jaundice  (itching,  slow 
pulse,  clay  colored  stools,  etc).  Bile  pigment  is  found  in  the  blood, 
not  in  the  urine  except  during  exacerbations  of  the  disease,  known  as 
"crises  of  deglobulization "  (Widal,  1908),  when  urobilinuria  may 
develop.  During  the  worse  phases  the  spleen  grows  larger,  the  urobilin- 
uria increases,  and  the  jaundice,  if  already  present,  deepens.  During 
the  better  phases  of  the  malady  the  red  blood  cells  vary  between 
three  and  four  millions;  in  the  bad  phases  they  fall  below  one 
million.  The  color  index  usually  is  below  i ;  the  hemoglobin  may  fall 
even  lower  then  20  per  cent.  The  red  blood  cells  show  anisocytosis, 
poikilocytosis,  and  polychromatophilia.  There  usually  are  some  cells 
with  granules,  and  there  may  be  even  normoblasts.  The  resistance  of 
the  red  blood  cells  is  diminished:  the  initial  hemolysis  may  be  0.60  and 
the  total  hemolysis  0.34.  The  white  blood  cells  vary  from  4500  to  11,500, 
usually  being  about  normal.  The  differential  count  varies  much  from 
time  to  time.  Myelocytes  are  seldom  found,  and  only  in  the  phases 
of  intense  anemia.  True  jaundice  may  not  develop  for  many  years; 
always  is  slight,  but  grows  worse  during  the  phases  of  severe  anemia. 
The  liver  often  is  enlarged,  especially  during  the  phases  of  severe 
anemia. 

In  the  congenital  cases,  or  at  least  in  childhood,  splenectomy 
is  not  as  definitely  indicated  as  in  adult  life.     In  the  latter  class  of 


752  SURGERY   OF    THE    SPLEEN 

cases,  according  to  Banti  (1912),  death  occurs  in  from  six  to  twelve 
years  unless  splenectomy  is  done,  and  this  is  the  only  measure  which 
has  any  effect.  Of  48  patients  on  whom  splenectomy  was  done, 
only  2  died  (Elliot  and  Kanavel,  1915):  three  patients  were  alive  and 
well  at  periods  of  27,  11,  and  6  years  respectively  after  operation; 
and  9  other  patients,  followed  for  6  months  after  operation,  remained 
in  good  health.  Of  27  patients  from  the  Mayo  Clinic  (1919)  treated 
by  splenectomy,  only  i  died;  all  the  others  who  were  not  in  the  terminal 
stages  of  the  disease,  were  cured. 

IM.\LARI.^L    SPLENOMEG.A.LY 

In  these  cases  also,  as  in  those  of  syphillis  of  the  spleen,  specific  treat- 
ment occasionally  fails  to  relieve  the  symptoms,  and  splenectomy  may 
then  prove  beneficial,  relieving  the  distressing  symptoms  due  to  the  im- 
mensely enlarged  spleen  itself,  and  permitting  seemingly  more  effective 
employment  of  antimalarial  remedies.  The  statistics  of  splenectomy  for 
malarial  splenomegaly  cited  by  Krumbhaar  (1918)  are  twenty  years  or 
more  old  and  though  the  mortality  at  that  time  was  very  high  (20  to  25 
per  cent.)  it  does  not  appear  that  later  operations  have  been  more  success- 
ful, though  no  extended  series  of  cases  appears  to  have  been  reported. 
In  our  first  edition  (1913)  we  tabulated  165  cases,  with  41  deaths,  a 
mortaUty  of  24.8  per  cent. 

Pernicious  Anemia 

Krumbhaar  (1918)  writes:  "The  most  important  disease,  from 
the  point  of  view  of  its  greater  frequency  and  greater  severity,  to  which 
splenectomy  has  been  applied  is  pernicious  anemia.  The  striking 
improvement  that  has  been  shown  to  follow  removal  of  the  spleen  in 
such  diseases  as  hemolytic  jaundice  and  Banti's  disease  naturally  led 
to  an  extension  of  this  clinical  procedure  to  allied  conditions.  In 
1913  three  investigators — Eppinger,  Decastello,  and  Klemperer 
working  independently,  tried  splenectomy  as  a  therapeutic  measure 
in  pernicious  anemia."  Though  they  were  induced  to  employ  splenec- 
tomy for  different  reasons,  they  agreed  in  the  expectation  that  removal 
of  the  spleen  should  favorably  affect  the  course  of  this  otherwise  hope- 
less disease:  Eppinger  expected  to  secure  a  diminished  output  of 
urobilin  and  other  evidences  of  hemolysis;  Decastello  seems  to  have 
regarded  the  improvement  which  followed  splenectomy  in  somewhat 
similar  conditions  as  sufficient  to  warrant  its  employment  in  pernicious 
anemia;  while  Klemperer  was  inffucnced  by  the  clinical  observation 


PERNICIOUS   ANEMIA  753 

that  splenectomy  in  the  healthy  individual  (for  rupture  of  the  spleen, 
etc.)  was  sometimes  followed  by  polycythemia. 

Krumbhaar,  whose  studies  in  this  field  no  one  can  afford  to  ignore, 
has  collected  153  cases  of  splenectomy  for  pernicious  anemia  in  which 
the  results  are  known:  there  were  30  deaths  (19.6  per  cent.)  soon  after 
operation;^  99  patients  (64.6  per  cent.)  were  improved  by  having 
their  spleens  removed,  and  only  24  (15.7  per  cent.)  showed  no 
improvement.  He  found  that  at  the  end  of  six  months  after  operation, 
of  53  patients  no  less  than  44  continued  to  improve,  9  had  already 
relapsed,  but  none  who  had  survived  splenectomy  for  more  than  six 
weeks  had  died  in  the  interval.  The  followining  table  shows  the  results 
in  cases  traced  b\  Krumbhaar  for  one  and  two  year  periods: 

Late  Results  .\fter  Splenectomv  for  PjJrincious  Anemia 

After  one  year      Aitei  two  years 

Number  of  patients  traced 27  6 

Still  improved 11  3 

Relapsed 7  2 

Died  subsequentlj' 9  i 

54  12 

As  to  the  selection  of  cases  for  operation,  we  cannot  but  agree  with 
Krumbhaar,  who  points  out  that  though  splenectomy  has  occasion- 
ally rescued  seemingly  moribund  patients  and  restored  them  to  com- 
parative health  for  many  months,  yet  that  its  effect  is  more  certain 
and  lasting,  and  the  danger  of  the  operation  is  less,  if  it  is  employed 
at  as  early  a  stage  of  the  disease  as  possible.  Especially  favorable 
cases,  he  finds,  are  those  patients  with  clinically  enlarged  spleens, 
icteroid  appearance,  and  increased  urobilin  output,  but  without 
increased  resistance  of  the  erythrocytes.  Splenectomy,  on  the  other 
hand,  he  regards  as  distinctly  contraindicated  in  cases  where  the  bone- 
marrow  is  persistently  aplastic;  and  it  is  not  apt  to  prove  beneficial 
when  spinal  cord  symptoms  have  already  developed. 

Before  splenectomy  is  undertaken  in  cases  of  pernicious  anemia,  it 
is  desirable  to  await  one  of  the  periods  of  apparently  spontaneous  im- 
provement which  frequently  occur;  and  to  employ  as  adjuvant  to 
this  spontaneous  improvement  transfusion  of  blood.  Splenectomy  may 
then  be  undertaken  with  fair  prospect  of  having  the  patient  survive 
and  securing  such  an  improvement  in  his  general  health  as  to  justify 
the  risk. 

'Mayo  (1919)  reports  from  the  Mayo  Clinic  50  splenectomies  for  pernicious  anemia 
with  3  deaths  (6  per  cent.). 
48 


754  SURGERY    OF    THE    SPLEEN 

After  splenectomy  forpernicious  anemia  it  is  usual  to  have  what  is 
known  as  a  "blood  crisis" — the  appearance  in  larger  quantities  in  the 
blood  of  normoblasts,  megaloblasts,  reticulated  erythrocytes,  Jolly 
bodies,  etc.  Subsequently,  as  the  blood  returns  nearer  to  normal,  the 
hemoglobin  and  red  blood  cell  count  rise,  but  the  color  index  usually 
remains  high.  In  no  case  has  a  permanent  cure  of  the  disease  been 
noted. 

Myelocytic  Leukemia 

The  mortality  of  splenectomy  for  this  condition  in  5 1  reported  cases 
(1918)  was  86  per  cent.  But  after  preliminary  radium  treatment  of 
the  enlarged  spleen,  it  has  -been  adopted  at  the  Mayo  Clinic  in  20 
cases,  with  only  one  death  (Gilfin,  1918);  so  it  is  apparent  that  this 
disease  also  is  coming  into  the  domain  of  surgery. 

Cirrhosis  of  the  Liver  with  Splenomegaly 

The  adoption  of  splenectomy  in  certain  cases  of  cirrhosis  of  the  liver 
attended  by  splenomegaly  was  discussed  at  p.  554. 

-    Injuries  of  the  Spleen 

These  may  be  divided  into  cases  oi.  subcutaneous  rupture,  almost 
always  due  to  indirect  violence,  or  to  blunt  force  if  the  injury  is  direct, 
and  open  uvunds,  especially  gunshot  and  stab  wounds. 

Disease  of  the  spleen  associated  with  enlargement  frequently 
is  a  predisposing  cause. 

Subcutaneous  Rupture. — If  the  spleen  is  normal  a  very  great 
degree  of  trauma  is  necessary  to  rupture  it.  Being  run  over  by 
vehicles,  falls  from  a  height,  kicks  and  crushes  are  the  usual  causes 
of  subcutaneous  rupture.  Violence  may  be  applied  directly  to  the 
spleen  beneath  the  costal  arch  or  indirectly  through  the  ribs.  In 
the  latter  case,  fracture  is  not  a  necessary  concomitant  as  the  spleen 
often  has  been  severely  injured  although  the  ribs  remained  intact. 
Rupture  from  indirect  violence  has  also  followed  blows  on  the  right 
side  and  even  falls  on  the  feet.  If  the  spleen  is  enlarged  it  is  easily 
ruptured  by  an  insignificant  degree  of  traumatism,  such  as  tightening 
a  belt,  coughing,  lifting,  etc.  This  violence  may  be  so  slight  that 
the  case  appears  almost  one  of  idiopathic  rupture,  but  in  the  majority 
of  cases  a  history  of  some  slight  injury  is  obtainable.  There  are, 
however,  a  certain  number  of  cases  in  which  rupture  has  occurred 
when  the  patient  was  lying  quietly  in  bed.  These  are  examples  of 
true  spontaneous  rupture,  although  they  are  the  result  of  advanced 
disease  of  the  spleen,  such  as  tuberculosis,  or  more  particularly  malaria. 


INJURIES  755 

In  the  tropics  rupture  of  a  malarial  spleen  is  a  common  cause  of  sudden 
death.  Labor  or  eclampsia  may  be  the  exciting  cause  of  rupture 
if  the  spleen  is  enlarged. 

Pathology. — ^Laceration  of  the  splenic  substance  varies  from  a 
sHght  subcapsular  rupture  of  the  pulp  to  complete  disorganization. 
The  spleen  may  be  divided  into  two  or  more  pieces  or  it  may  be  com- 
pletely torn  away  from  its  vessels.  Hemorrhage  is  the  most  important 
factor.  If  the  capsule  is  torn  the  blood  is  poured  out  into  the  general 
peritoneal  cavity  and  the  spleen  shows  only  the  rent  in  its  substance. 
If  the  capsule  is  untorn  (subcapsular  rupture)  the  blood  collects 
beneath  it  and  forms  a  hematoma.  As  the  pressure  increases,  it  may 
cause  cessation  of  the  bleeding  or  rupture  of  the  capsule.  In  the 
former  case  a  hemorrhagic  cyst  is  formed,  in  the  latter,  a  frank  rupture. 
If  clotting  occurs  and  bleeding  stops,  the  future  condition  of  the 
spleen  depends  on  the  degree  of  injury.  If  any  of  the  main  vessels 
are  involved  necrosis  will  follow.  If  only  the  splenic  pulp  is  torn,  the 
wound  may  heal,  or,  as  is  more  Ukely,  softening  of  the  clot  will  lead 
to  secondary  hemorrhage  in  a  few  days. 

Site  of  Rupture. — If  extensive  injuries  involving  a  large  portion 
of  the  splenic  substance  are  excluded,  the  site  of  rupture  occurs  five 
to  six  times  more  frequently  on  the  internal  surface  than  on  all  the 
rest  of  the  surfaces  collectively.  Frequently  the  laceration  extends 
from  the  inner  to  one  or  more  of  the  other  surfaces.  If  the  rupture  is 
hmited  to  the  internal  surface  immediately  behind  the  hilum  the 
bleeding  may  be  confined  to  the  lesser  peritoneal  cavity. 

Rupture  of  Enlarged  Spleen. — The  same  lesions  occur  as  in  the 
normal  spleen,  and  the  difference  in  morbid  anatomy  is  that  the 
spleen  shows  the  changes  characteristic  of  the  pathological  process 
to  which  it  is  subject. 

Injury  to  Other  Organs. — On  account  of  its  position,  rupture  of 
the  spleen  frequently  is  accompanied  by  injury  to  one  or  more  of  the 
surrounding  organs,  stomach,  liver,  intestine,  kidney,  pancreas  and 
suprarenal  gland.  These  injuries  vary  in  severity  as  do  those  in  the 
spleen.  Fracture  of  the  ribs  and  bruises  on  the  surface  of  the  body 
may  indicate  the  point  of  application  of  the  causative  force,  but  very 
often  there  is  no  external  evidence  of  injury. 

Penetrating  Wotinds. — Stab  wounds  vary  in  depth  and  breadth 
according  to  the  size  of  instrument  and  its  depth  of  penetration. 
Gunshot  wounds  may  cause  great  disorganization  of  the  spleen  or 
only  small  wounds  of  entrance  and  exit. 

Injury  to  the  surrounding  structures  is  even  more  frequent  than  in 
subcutaneous  rupture,  particularly  in  gunshot  wounds. 


756  SURGERY    OF    THE    SPLEEN' 

Thevenot  (1910)  collected  eighty-one  cases  of  gunshot  and  stab 
wounds  of  the  spleen,  and  twenty-four  of  them  were  complicated 
by  wounds  of  one  or  more  of  the  surrounding  viscera.  The  viscera 
injured  were  the 

Stomach in  14  instances. 

Liver in    5  instances. 

Kidney in    4  instances. 

Intestine in    5  instances. 

Omentum in     >  instances. 

Lungs  in    2  instances. 

In  several"  cases  more  than  one  other  organ  was  injured.  In 
addition,  the  diaphragm  and  pleura  are  involved  more  frequently 
than  any  of  the  viscera.  Among  54  cases  of  gunshot  wounds  of  the 
spleen  studied  by  Wallace  (1917),  only  32  were  uncomplicated  by 
other  visceral  injuries. 

Symptoms. — As  the  symptoms  from  subcutaneous  and  penetrating 
wounds  do  not  differ  very  much,  they  may  be  considered  altogether. 

They  vary  from  sudden  and  immediate  death,  to  the  gradual 
or  sudden  onset  of  symptoms  seventy-two  hours  or  more  after  the 
injury.  Sudden  death  may  not  be  attributable  solely  to  the  splenic 
injur}'  but  may  be  due  chiefly  to  complicating  lesions.  When  the 
onset  of  symptoms  is  delayed,  it  is  probable  that  the  original  injury 
produced  a  subcapsular  hematoma  which  subsequently  ruptured; 
or  a  primary  complete  but  small  rupture  may  have  been  sealed  tempor- 
arily by  clotting,  and  the  late  symptoms  may  be  caused  by  dislodgment 
of  this  clot  with  secondary  hemorrhage.  In  either  case  the  symp- 
toms, although  appearing  late,  are  the  same  as  those  that  occur 
immediately  after  the  injury. 

Sudden,  severe  pain  occurs  in  the  left  hypochondrium  accompanied 
by  a  sense  of  tearing.  The  symptoms  of  internal  hemorrhage  appear 
with  a  varying  degree  of  rapidity.  Subsequently  the  pain  in  the  left 
hyponchondrium  varies  in  severity  from  a  more  or  less  continuous  dull 
ache,  with  acute  exacerbations,  to  pain  so  insignificant  as  to  be  almost 
negligible.  Levy  (1908)  called  attention  to  the  value  of  sharp  pain  in 
the  left  shoulder  region  as  a  sign  of  rupture  of  the  spleen.  Breathing 
and  moving  aggravate  whatever  pain  is  present.  The  time  of  appear- 
ance of  the  signs  and  symptoms  of  internal  hemorrhage  depends  on  the 
rapidity  of  the  bleeding;  very  often  a  large  amount  of  blood  escapes 
slowly  into  the  abdomen  before  appreciable  symptoms  appear.  The 
two^most  important  signs  are  increasing  pallor  and  rise  in  the  pulse 
rate  with  diminution  of  its  volume.     Subsequently  the  patient  exhibits 


INJURIES  757 

a  rapid,  running  pulse,  restlessness,  vomiting,  air  hunger,  and  other 
signs  of  severe  internal  hemorrhage.  Abdominal  distention  with  rigidity 
more  or  less  localized  to  the  left  upper  quadrant  may  be  present,  and 
with  these  signs  there  may  be  increase  in  the  area  of  splenic  dullness 
and  dullness  in  the  left  flank  instead  of  the  normal  resonance.  Dull- 
ness in  the  flank  when  present  often  is  not  a  shifting  dullness.  Fre- 
quently all  these  signs  are  absent  although  there  is  an  extensive 
laceration.  Tenderness  over  the  spleen  usually  is  demonstrable  either 
from  in  front  or  behind. 

Rupture  in  the  course  of  typhoid  fever  as  a  rule  is  mistaken  for  intes- 
tinal perforation.  The  rupture  is  manifested  by  pain  beginning  in  the 
splenic  region,  by  marked  abdominal  rigidity,  followed  by  distention, 
with  small  rapid  pulse,  and  extreme  toxemia.  A  drop  of  the  tempera- 
ture to  subnormal  may  occur  at  the  time  of  ru[Jture,  as  in  cases  of  intes- 
tinal perforation,  but,  as  also  in  these  cases,  the  temperature  rises  as 
peritonitis  develops.  Bryan  (1909)  collected  35  cases  of  spontaneous 
rupture  of  the  typhoid  spleen. 

Rupture  of  a  malarial  spleen  causes  the  rapid  appearance  of  shock 
from  internal  hemorrhage,  and  in  most  cases  this  is  quickly  fatal. 

Diagnosis. — History  of  an  injury,  pain  in  the  left  hypochondrium, 
symptoms  of  internal  hemorrhage,  dullness  in  the  flank  and  localized 
rigidity,  when  present  all  together  leave  very  httle  doubt  of  the  diagnosis. 
Injury  to  the  kidney  is  ruled  out  by  the  absence  of  blood  in  the  urine. 
Intestinal  injury  gives  rise  to  earlier  and  more  marked  abdominal  rigidi- 
ty, which  usually  is  more  generalized;  and  the  symptoms  of  internal 
hemorrhage  are  likely  to  be  less  severe  unless  the  mesenteric  vessels 
arc  torn  across.  The  site  of  the  blow  usually  excludes  hver  injury; 
but  in  certain  cases,  and  particularly  those  where  the  splenic  rupture 
is  due  to  indirect  violence,  diiTerentiation  is  practically  impossible. 
Rupture  of  the  pancreas  rarely  occurs  without  injury  to  the  surround- 
ing organs  and  it  frequently  is  involved  with  the  spleen.  The  stomach 
and  gall-bladder  rarely  are  injured  except  in  the  case  of  penetrating 
wounds.  Stomach  injury  may  lead  to  hematemesis;  otherwise  the 
symptoms  are  those  of  intestinal  rupture.  Laceration  of  the  gall- 
bladder resembles  injury  to  the  liver  except  that  the  symptoms  of 
hemorrhage  are  not  marked. 

As  the  treatment  for  all  these  conditions  is  the  same,  laparotomy, 
time  ought  not  to  be  wasted  in  attempting  to  differentiate,  but  opera- 
tion should  be  undertaken  as  soon  as  it  is  evident  that  there  has  been 
visceral  injury.  If  the  surgeon  waits  for  shock  to  subside  few  patients 
will  be  saved  from  death. 


758  StTRGERY    OF    THE    SPLEEN 

Prognosis  and  Treatment. — The  treatment  of  splenic  injuries 
is  immediate  laparotomy.  Tliis  is  followed  by  packing  of  the  wound, 
by  its  suture,  or  by  splenectomy,  according  to  the  extent  of  the  injury 
to  the  spleen.  The  mortality  of  cases  in  which  no  operation  is  done  is 
95  per  cent,  or  more.  The  operative  mortality  is  about  33  per  cent.; 
this,  however,  does  not  represent  the  full  mortality  of  rupture  of  the 
spleen,  as  many  patients  die  too  soon  to  allow  time  for  operation. 
There  are  several  reported  recoveries  from  injuries  that  could  not  be 
distinguished  clinically  from  rupture,  but  there  must  always  be  a  large 
element  of  doubt  in  the  diagnosis  when  the  patient  recovers  without 
operation. 

Operative  Treatment.^The  incision  should  be  made  in  the  epi- 
gastrium parallel  to  and  just  to  the  left  of  the  middle  line,  so  as  to  per- 
mit thorough  exploration  and  treatment  of  concomitant  injuries. 

The  operation  selected  depends  upon  the  position  and  extent  of 
the  injury.  Splenectomy  is  more  often  undertaken  than  all  other 
operations  combined,  but  repair  of  the  wound,  plugging  with  gauze, 
and  suture  of  the  omentum  to  the  wound  have  all  been  recommended 
and  performed  with  success. 

Splenectomy  is  done  most  frequently  because  it  is  the  most  certain 
way  to  stop  the  bleeding;  bcause  the  operation  is  easily  performed 
in  the  majorit}^  of  cases;  and,  more  particularly,  because  the  greater 
number  of  splenic  injuries  are  of  such  a  nature  that  they  cannot  be 
treated  in  any  other  manner  with  a  reasonable  hope  of  success.  There 
were  reported  in  the  first  edition  of  this  work  227  cases  of  splenectomy 
for  injury  with  155  recoveries  and  72  deaths,  a  mortality  of  31  percent.; 
and  more  recent  reports  indicate  that  the  death  rate  continues  at 
least  as  high;  but  it  must  be  remembered  that  in  a  large  proportion  of 
the  fatal  cases  there  were  other  visceral  injuries.  According  to  Wallace 
(191 7)  in  32  uncomplicated  cases  the  mortality  was  50  per  cent.; 
and  63  per  cent,  in  23  complicated  cases. 

Suture. — Even  when  the  injury  is  small  it  is  very  difficult  to  control 
the  hemorrhage  with  sutures.  In  a  report  of  134  cases  of  rupture  of 
the  spleen,  Lotsch  (1908)  gave  the  following  results:  splenectomy,  118 
cases  with  fifty-two  deaths;  splenorrhaphy,  eight  cases  with  three 
deaths;  tamponade,  eight  cases  with  two  deaths.  Kirschner  (1909) 
described  a  method  of  encapsulating  the  wound  by  sewing  the  omentum 
to  the  edges.  He  operated  on  four  cases  with  one  death,  and  in  this 
case  operation  was  refused  until  the  patient  was  almost  moribund. 

Tamponade. — The  advantage  of  plugging  with  gauze  is  that  the 
spleen  is  preserved.     This  undoubtedly  furnishes  a  strong  argument 


ANEURYSM   OF   THE    SPLENIC   ARTERY  759 

in  its  favor,  but  the  control  of  hemorrhage  is  uncertain  in  all  but  the 
most  favorable  cases.  Tamponade  is  particularly  indicated  in  those 
cases  where  the  presence  of  perisplenic  adhesions  renders  splenectomy 
difficult  or  impossible.  It  may  be  advisable  to  soak  the  gauze  in 
adrenalin  solution. 

Temporary  Clamping  of  Vessels. — Sheldon  (1910),  as  a  result  of 
experimental  work  on  dogs,  advises  the  use  of  rubber-covered  clamps 
applied  to  the  pedicle  for  four  hours.  They  should  then  be  loosened 
and  if  hemorrhage  does  not  recur  may  be  removed.  They  may  be 
reapplied  for  another  two  hours  if  hemorrhage  persists.  In  his  experi- 
ments hemorrhage  did  not  recur  when  the  clamp  was  removed  in  four 
hours.  The  splenic  wound  is  not  treated.  By  this  means  the  vessels 
empty  themselves  without  clotting.  If  the  wound  is  packed  the  clot 
extends  back  through  the  vessels  to  the  clamp  and  necrosis  might 
result. 

Ligation  oj  the  splenic  Artery  through  the  Gastro-hepatic  Omentum, 
was  suggested  by  John  Gerster  (1915)  as  an  easy  method  of  control- 
ling hemorrhage  from  the  spleen,  and  it  might  be  of  value  in  some 
traumatic  lesions  where  exposure  of  the  splenic  pedicle  proved  difficult. 
(Fig.  197.) 

Aneurysm  of  the  Splenic  Artery 

Splenectomy  for  Aneurysm  of  the  Splenic  Artery  was  done  success- 
fully by  Winckler  (1905),  who  refers  to  one  similar  operation  by 
Selten,  and  says  that  Ponfick  had  found  an  aneurysm  of  the  splenic 
artery  four  times  at  autopsy.  Villard  and  Murard  (191 2)  attempted 
splenectomy  in  one  case,  but  adhesions  rendered  this  impossible. 
The  pedicle  of  the  aneurysmal  tumor  had  to  be  clamped  to  check 
bleeding,  and  the  clamps  were  left  in  place,  as  Hgation  was  impossible. 
The  patient  died  in  ten  days  from  secondary  hemorrhage.  In  both 
Winckler 's  and  Villard 's  patients  the  chief  symptoms  were  recurring 
attacks  of  pain  of  some  years'  duration.  In  both  the  operation  was 
exploratory,  a  correct  diagnosis  not  having  been  made  before  opening 
the  abdomen. 


CHAPTER  XXIV 


TECHNIQUE  OF  OPERATIONS 


General  Considerations. — In  the  First  Part  of  this  work  (p.  309) 
we  have  covered  so  fully  the  subject  of  preparation  of  the  patient  and 
after-treatment  that  nothing  additional  need  be  said. 

Operations  ox  the  Gall-bladder  axd  Bile-ducts 

Position  of  the  Patient. — The  patient  is  placed  in  the  dorsal  position 
with  a  sand  bag  or  lirm  pillow  beneath  the  back  at  the  level  of  the 
liver.  This  pillow  should  be  about  45  cm.  long,  and  cylindrical 
in  shape;  its  diameter  should  be  from  10  to  15  cm.  Instead  of^a 
pillow  a  special  operating  table  may  be  used,  provided  with  an  adjust- 


FiG.   172. — Patient  in  Position  for  Bile-duct  Operations. 

able  "bridge."     When  properly  placed   this  pillow  raises  the  lower 

dorsal  and  upper  lumbar  spine  away  from  the  tabic  in  such  a  manner 

that  the  liver  and  biliary  passages  are  pushed  forward,   the  costal 

angle  is  widened,  and  the  intestines  fall  by  gravity  toward  the  pelvis. 

A  pillow  or  two  should  be  placed  beneath  the  head  and  shoulders 

to  relieve  tension  on  the  neck  and  to  raise  the  head  to  a  proper  level 

for  the  administration  of  the  anesthetic  (Fig.  172).     Elliot,  of  Boston, 

who  introduced  this  position  in  1895,  also  raised  the  head  of  the  table 

(reversed   Trendelenburg   position);    and    in    difficult    cases    this    has 

much  to  commend  it. 

760 


GALL-BLADDER    INCISIONS  76 1 

Incision. — Numerous  incisions  have  been  advocated  as  best  adapted 
for  exposing  the  gall-bladder  and  common  duct.  Some  of  these  are 
objectionable,  because  disregarding  important  structures  in  the 
abdominal  wall,  especially  the  nerves,  and  thus  predisposing  to  hernia 
or  muscular  atrophy.  Particular  attention  was  called  to  this  danger 
from  nerve  injury  by  Assmy  in  1899  though  it  had  been  pointed  out 
by  Kocher  before  1894. 

Courvoisier's  Incision  (1890)  runs  parallel  to  the  costal  margin 
from  the  ensiform  to  the  flank;  all  structures  of  the  abdominal  wall 
are  divided  in  the  same  line.  Though  this  incision  gives  ample 
exposure  it  is  objectionable  because  it  cuts  all  the  lower  intercostal 
nerves.  Kocher' s  incision  (1894)  is  similar  to  Courvoisier's  but  a 
little  shorter  and  more  transverse. 

Lau'son  Tail  (1879)  and  Riedel  (1892)  used  a  longitudinal  incision 
through  the  right  rectus  muscle;  and  this  is  sufficient  for  ordinary 
cases  of  cholecystostomy. 

Langenbuch's  incision  (1896)  consists  of  a  longitudinal  cut  along  the 
right  semilunar  line,  when  necessary  combined  with  an  oblique  incision 
along  the  costal  margin  to  the  ensiform;  or  a  longitudinal  incision 
through  the  rectus  (as  in  Riedel 's  method),  combined  when  necessary 
with  an  oblique  incision  along  the  costal  margin  inward  to  the  ensiform 
or  outward  as  far  as  necessary. 

Mayo  Robson's  incision  (1897)  is  similar  to  Langenbuch's  second 
method — a  longitudinal  incision  through  the  outer  third  of  the  right 
rectus  muscle,  with  an  upward  and  inward  extension  along  the  costal 
margin  to  the  ensiform  (Fig.  173).  This  is  the  incision  used  habitually 
by  the  senior  author,  and  he  finds  it  adequate  even  in  difficult  cases. 
Yet  Terrier,  than  whom  no  more  skillful  and  experienced  operator  on 
the  biliary  tract  has  ever  lived,  declared  (1905)  this  incision  not  suffi- 
cient, and  for  difficult  cases  preferred  Kehr's  incision. 

Kelir's  incision  (1905),  known  as  the  Wellenschnilt,  and  the  Bayonet 
incision,  begins  at  the  ensiform,  passes  down  3  to  4  centimetres  in 
the  mid-Hne,then  cuts  the  right  rectus  as  far  as  its  outer  third  (parallel 
to  the  costal  margin)  between  its  linea  transversa  and  the  umbilicus, 
and  thence  continues  longitudinally  downward  as  far  as  the  umbilicus 
or  lower.  There  is  no  doubt  that  this  immense  incision  gives  very 
excellent  exposure  of  the  deeper  biliary  passages,  but  we  have  never 
felt  inclined  to  adopt  it,  having  found  we  could  accomplish  everything 
necessary  through  a  simpler  incision.  If  Kehr's  incision  is  carefully 
sutured,  and  no  wound  infection  occurs,  it  does  not  appear  to  pre- 
dispose the  patient  to  hernia  more  than  the  other  incisions  employed. 


762 


TECHNIQUE    OF    OPERATIONS 


Gosset  (191 2)  found  that  among  142  operations  in  which  drainage 
had  been  employed  after  the  use  of  Kehr's  Wellenschnitt,  a  hernia 
resulted  only  in  four  instances.  It  cuts  no  more  nerves  than  Robson's 
incision,  and  di\ddes  the  rectus  in  precisely  the  same  manner,  only 
a  little  lower.  Of  late  Kehr  has  abandoned  the  lower  limb  of  his 
original  incision,  so  that  the  method  he  now  adopts  somewhat  resembles 
that  of  Czerny  (p.  763). 


^^^^I^^mi^^^^^^^HI 

'^^ 

r 

■ 

^mammm    . 

Fig.    173. — Scar  Resulting  from  Robson's  Incision.      (Ashhursl.) 


Collins' s  incision  (1908)  "begins  at  the  inner  edge  of  the  right 
rectus  muscle  i  or  2  inches  (2.5  to  5  cm.)  from  the  ensiform  cartilage, 
and  extends  diagonally  downward  and  outward  to  the  outer  edge  of 
the  right  rectus  close  to  the  level  of  the  umbiHcus.  It  cuts  through 
the  skin,  fat  and  anterior  wall  of  the  sheath  of  the  rectus.  A  short 
transverse  incision  about  i  inch  in  length  may  be  made  inward  from 
the  upper  end  of  the  obhque  incision  through  the  skin,  fat  and  linea 
alba;  and  a  similar  one  through  the  hnea  semilunaris  at  the  lower 
end.  The  rectus  muscle  is  then  separated  from  its  sheath.  When 
the  muscle  is  thoroughly  freed  from  its  sheath,  except  at  its  outer 
border,  it  is  easily  retracted  outward  and  allows  the  posterior  sheath 
and  the  peritoneum  to  be  incised  in  the  same  direction  as  the  skin 
and  anterior  wall."  Colhns  points  out  that  transverse  division  of 
both  linea  alba  and  linea  semilunaris  permits  the  wound  to  gape  widely, 


GALL-BLADDER   INCISIONS  763 

but  that  suture  is  easy  and  repair  very  efficient.  The  junior  author 
habitually  employs  this  incision,  being  influenced  by  the  fact  that 
it  does  not  damage  the  motor  nerves  to  the  rectus,  and  being  near 
the  midhne  gives  adequate  exposure  of  the  ducts.  Terrier's  maxim, 
that  biliary  surgery  tends  to  become  more  and  more  canaliculaire, 
should  be  kept  in  mind. 

Czerny's  Incision. — Czerny  described  his  Winkelschnilt  in  1892; 
and  Kocher  finally  (191 1)  adopted  a  modification  of  it  as  his  own 
"normal  incision  for  difficult  cases  as  did  Perthes  (1912).  The 
original  incision  ran  for  from  5  to  7  centimeters  in  the  mid-line,  above 
the  umbilicus,  and  bent  just  below  the  umbilicus  to  the  right,  cutting 
the  right  rectus  muscle  transversely.  As  employed  by  Kocher, 
Perthes,  and  other  surgeons  in  recent  years,  the  longitudinal  part  of 
the  incision  has  been  longer,  extending  from  the  ensiform,  close  to 
the  midline,  almost  to  the  umbilicus,  where  it  cuts  the  right  rectus 
transversely. 

Sprengel's  Transverse  Incision. — Sprengel  (1910)  described  a 
transverse  incision  for  operations  on  the  bile  passages,  which  has 
been  adopted  by  Gosset  (191 2)  in  France,  and  for  which  Moschcowitz 
(1916)  has  made  himself  the  protagonist  in  this  country. 

Sprengel's  transverse  incision  divides  the  right  rectus  muscle 
directly  across  at  whatever  level  seems  desirable,  depending  upon 
the  distance  that  the  liver  extends  beyond  the  costal  margin.  If 
the  suspensory  ligament  of  the  liver  is  in  the  way,  it  should  be  divided. 
Kehr  objected  to  the  use  of  this  incision  as  consuming  too  much  time. 
He  speaks  of  fifteen  or  twenty  minutes  as  required  before  the  abdomen 
is  opened.  Gosset  found  it  took  him  only  from  two  to  three  minutes 
to  make  the  whole  incision.  Only  in  exceptional  cases  is  it  necessary 
to  divide  part  of  the  left  rectus,  to  gain  sufficient  exposure.  Division 
of  both  semilunar  line  and  linea  alba  permits  wide  retraction.  It  is 
well  to  follow  the  advice  of  Perthes  (191 2),  to  suture  the  anterior 
sheath  to  the  rectus  muscle  on  both  sides  of  the  incision  before  the 
muscle  is  divided:  this  prevents  both  retraction  of  the  transversely 
cut  muscles  and  annoying  bleeding.  This  incision  gives  ample  ex- 
posure, there  is  little  tendency  for  prolapse  of  the  intestines  even 
when  the  patient  strains;  and  probably  the  chief  advantage  of  all, 
it  is  a  wound  easily  closed,  inasmuch  as  there  is  no  tendency  for  it  to 
gape  during  contractions  of  the  oblique  muscles.  Moreover,  the 
posterior  sheath  of  the  rectus  holds  sutures  better  after  transverse 
than  after  longitudinal  division. 

Sevan's  incision  (1899)  begins  near  the  ensiform  cartilage,  runs 


764  TECHNIQUE    OF    OPERATIONS 

parallel  with  the  costal  margin  as  far  as  the  linea  semilunaris,  then 
extends  along  this  line  about  10  to  12  cm.  and  finally  is  carried  trans- 
versely outward,  thus  making  an  elongated  S-shaped  incision.  In 
simple  cases  neither  the  inner  nor  outer  extension  of  the  longitudinal 
incision  need  be  employed.  It  is  then  the  same  as  Langenbuch's 
original  incision.  When  both  the  inward  and  outward  extensions  are 
used,  it  does  more  damage  to  the  abdominal  nerv'es  than  any  incision, 
except  Courvoisier's,  ever  devised. 

As  stated  already,  of  all  these  incisions  the  senior  author  prefers 
Mayo  Robson's.  In  simple  cases  the  longitudinal  portion  alone  is 
used,  spHtting  the  fibres  of  the  rectus  muscle  parallel  to  their  course. 
If  more  room  is  needed,  the  incision  is  continued  inward  and  upward, 
parallel  but  not  too  close  to  the  costal  margin,  into  the  space  between 
the  ensiform  process  and  the  ribs.  If  the  incision  passes  too  close 
to  the  ribs  difficulty  will  be  experienced  in  suturing  it,  on  account  of 
the  retraction  of  the  fiat  muscles  on  the  outer  side  of  the  wound. 
This  incision  of  Robson's  cuts  only  a  few  of  the  upper  abdominal 
nerves,  and  only  after  they  have  entered  the  rectus  muscle. 

When  the  time  comes  to  suture  any  of  these  upper  abdominal 
incisions,  closure  is  much  facilitated  by  removing  the  sand  pillow  or 
support  from  beneath  the  patient,  and  thus  relaxing  the  abdominal 
wall.  When  this  is  done,  it  should  not  be  forgotten  that  the  bile 
passages  will  recede  at  once  from  the  anterior  abdominal  wall,  and 
that  the  drainage  may  become  displaced  if  not  sufficiently  long  or 
firmly  fixed. 

After  the  abdomen  has  been  opened,  recognition  of  the  anatomical 
landmarks  and  relative  position  of  the  viscera  is  of  the  greatest  im- 
portance As  a  preliminary  to  exploration,  the  upper  right  abdominal 
region  should  be  isolated  with  pads  of  gauze,  wrung  out  of  hot  saline 
solution:  the  first  is  passed  toward  the  median  line  pressing  the  duode- 
num and  stomach  away  from  the  liver  and  gall-bladder ;  a  second  depresses 
the  colon;  while  a  third  is  passed  into  the  subhepatic  space,  to  the  right 
of  the  incision.  Even  after  the  diseased  area  has  been  walled  ofif  in 
this  way,  recognition  of  the  anatomical  landmarks  of  the  biliary  tract 
is  often  the  most  difficult  step  encountered  throughout  the  entire 
procedure,  especially  in  those  cases  where  repeated  attacks  of  inflam- 
mation have  bound  the  various  structures  into  an  almost  homogeneous 
mass  by  dense  adhesions.  These  adhesions  must  be  separated  suffi- 
ciently to  allow  proper  surgical  treatment  of  the  lesions,  but  we  do 
not  advocate  unnecessary  interference  with  adhesions  which  often  are 
nature's   barrier   against   infection  of  the  general  peritoneal  cavity. 


EXPOSURE    OF    THE    GALL-BLADDER    AND    DUCTS 


765 


The  adhesions  should  be  approached  from  the  convex  surface  of  the 
Hver,  the  border  of  the  liver  in  the  region  of  the  normal  site  of  the 
gall-bladder  being  freed  first.  From  this  point  of  entrance  to  the 
anatomy  of  the  biliary  passages,  careful  separation  of  the  adhesions 
should  be  continued  until  the  symptom-producing  lesions  have  been 
uncovered. 

When  possible,  the  lower  border  of  the  liver  should  be  drawn  down- 
ward and  then  lifted  upward  into  the  abdominal  incision  sUghtly 
rotating  the  organ  around  an  antero-posterior  axis,  so  as  to  turn  its 


Q-, 


■A 


Pig.  174. — Rotation  of  .the  Liver  to  E.xpose  the  Gall-bladder  and  Bile-ducts. 


inferior  surface  toward  the  left  of  the  patient  (Fig.  174).  This  can  be 
done  in  most  cases  where  the  anterior  border  of  the  liver  is  not"  held 
too  firmly  in  place  by  adhesions.  It  may  be  facilitated  by  division  of 
the  falciform  ligament,  as  recommended  by  Judd  (1916),  with  its 
restoration  by  suture  at  the  close  of  the  operation.  This  lifting  of  the 
anterior  border  of  the  liver  fully  exposes  the  gall-bladder  and  the  cystic 
and  common  ducts  which  are  thus  brought  very  near  the  surface. 
It  may  be  noted  as  pointed  out  by  Robson  (1904)  that,  "with  the  liver 
in  this  position,  the  cystic  duct  does  not  form  an  angle  with  the  common 
duct,  but  instead  an  almost  straight  passageway  is  found  from  the  fundus 
of  the  gall-bladder  to  the  entrance  of  the  bile-duct  into  the  duodenum." 


766  TECHNIQUE    OF    OPERATIONS 

The  ducts  are  fully  exposed  to  view  and  with  the  palpating  finger  the 
surgeon  may  determine  readily  the  condition  of  the  ducts,  the  duodenum, 
the  pylorus,  the  pancreas  and  the  regional  lymph-nodes. 

Very  few  special  instruments  are  required.  For  the  removal 
of  the  bile  from  the  gall-bladder  a  trocar  and  caniila  with  a  rubber 
tube  attached  may  be  employed.  The  canula  should  be  large  enough 
to  permit  the  flow  of  thick,  tarry  bile  and  the  rubber  tube  may  be 
attached  to  a  vacuum  bottle  or  a  suction  syringe  may  be  used.  A 
spoon  scoop,  such  as  designed  by  Robson,  is  of  great  service  in  removing 
calculi  from  the  gall-bladder  or  ducts.  Large  and  small  gall-stone 
forceps  should  also  be  provided.  The  ordinary  small  teaspoon  answers 
admirably  for  removing  stones  from  the  gall-bladder.  A  malleable 
lead  sound,  or  flexible  bougies,  should  also  be  at  hand  for  exploration  of 
the  ducts.  Retractors,  long  enough  to  reach  from  the  surface  of  the 
fattest  abdomen  to  the  region  of  the  common  duct,  are  indispensable. 
A  malleable  retractor  about  7  cm.  wide  and  35  to  45  cm.  long  is  very 
convenient. 

Rubber  tubing  is  needed  in  aU  cases  of  drainage  of  the  biliary  tract, 
either  of  the  gall-bladder  or  the  ducts.  We  prefer  tubing  with  a  lumen 
of  about  0.5  cm.  for  draining  the  gaU-bladder;  the  tubing  for  the  ducts 
should  be  small  enough  to  enter  the  lumen  of  the  duct  easily,  yet 
large  enough  to  prevent  leakage  around  the  tube.  A  T-shaped  piece 
of  tubing  is  used  at  times  to  drain  the  common  and  the  hepatic  ducts 
as  well  as  for  reconstruction  of  the  lumen  of  the  common  duct.  The 
senior  author  has  used  for  some  years  a  specially  constructed  drainage 
tube  for  the  gall-bladder.  This  is  made  by  wrapping  a  thin  layer  of 
gauze  around  a  rubber  tube  (0.5  cm.  lumen),  and  surrounding  this 
gauze  with  rubber  tissue  or  preferably  rubber  dam.  The  rubber 
tissue  or  rubber  dam  and  gauze  are  held  in  place  by  catgut,  tied  around 
the  whole  in  several  places. 

A  sterile  hypodermic  syringe  always  should  be  part  of  the  armamen- 
tarium in  gall-stone  operations,  to  be  used  to  identify  the  common 
duct  before  incising  it.  This  precaution  of  Terrier's  (1905)  will  save 
the  surgeon  much  uncertainty  in  cases  where  the  choledochus  is  dilated 
and  cannot  otherwise  be  distinguished  from  the  portal  vein. 

Cholecystendysis  or  Cholecystotomy  without  drainage  has  been 
abandoned  by  most  surgeons,  as  the  indications  for  its  use  are  so  seldom 
seen.  The  operation  was  first  performed  in  1883  by  ^leredith.  Cour- 
voisier  performed  it  in  1884  under  the  name  of  cholecystendysis. 
We  think  this  practice  is  to  be  condemned.  The  supposed  indication 
is  to  remove  gall-stones  from  the  gall-bladder,  in  the  presence  of  abso- 


CHOLECYSTOSTOMY  767 

lutely  clear  and  free  cystic  and  common  ducts,  and  in  the  absence  of 
infection.  It  should  not  be  performed  if  there  is  doubt  about  a  calculus 
being  overlooked  either  in  the  gall-bladder  or  in  the  ducts;  nor  if 
the  lumen  of  the  cystic  duct,  the  common  duct  or  the  hepatic  duct 
is  even  slightly  narrowed  by  inflammatory  deposits  or  cicatricial 
contractions;  nor  if  the  gall-bladder  walls  or  its  contents  show  any 
evidence,  however  slight,  of  infection. 

In  exploratory  operations  upon  the  gall-bladder,  it  may  be  de- 
sired to  know  the  general  characteristics  of  the  bile,  and  without  making 
a  formal  opening  into  the  organ,  a  hypodermic  needle  may  be  inserted 
and  some  of  the  bile  aspirated  for  study.  The  opening  made  by  the 
needle  requires  no  suture. 

Operation. — The  gall-bladder  is  exposed  and  isolated  by  gauze 
packs,  as  in  other  operations  upon  the  biliary  tract.  Its  fluid  contents 
are  removed  by  aspiration,  it  is  opened,  and  the  calculi  re- 
moved. The  wound  in  the  gall-bladder  is  then  closed  with  a  row  of 
plain  catgut  sutures  which  pass  through  all  of  the  coats  of  the  viscus, 
and  these  are  reinforced  by  a  continuous  Lembert  suture,  of  chromic 
or  iodized  catgut.  Non-absorbable  suture  material  should  not  be  used 
for  fear  of  its  ulcerating  into  the  lumen  of  the  gall-bladder  and  forming 
a  nucleus  for  a  stone.  The  gall-bladder  is  dropped  back  into  place, 
the  gauze  pads  are  removed,  and  the  wound  in  the  abdominal  wall  is 
closed  in  tiers  without  drainage.  It  is  always  advisable  to  use  two  or 
more  interrupted  silk-worm-gut  sutures  running  down  to  the  periton- 
eum through  all  layers  of  the  abdominal  wall  ("splint  sutures")  as 
advised  at  page  315. 

Cholecystotomy  and  Cholecystostomy. — The  two  terms,  cholecys- 
totomy  and  cholecystostomy,  are  used  as  synonyms  by  most  authors 
and  writers.  On  historical  grounds  it  might  be  preferable  to  employ 
the  term  cholecystotomy  to  designate  solely  the  operation  of  opening 
and  draining  the  gall-bladder  as  usually  done,  and  to  reserve  the  term 
cholecystostomy  to  designate  the  operation  of  draining  the  gall-bladder 
by  attaching  it  to  the  parietal  peritoneum  or  anterior  sheath  of  the 
rectus,  as  is  done  when  very  prolonged  drainage  is  desired  (cases  of 
pancreatitis,  etc.) ;  but  the  terms  are  in  such  general  use  as  synonyms 
that  the  distinction  is  of  questionable  value.  In  many  cases  the  drain- 
age of  the  gall-bladder  is  merely  incidental  to  a  more  important  pro- 
cedure, such  as  removal  of  calculi,  or  evacuation  of  an  empyema;  in 
such  cases  opening  and  not  drainage  of  the  gall-bladder  constitutes 
the  main  therapeutic  indication.  Cholecystendysis  is  best  reserved 
to  describe  the  suture  and  replacement  of  the  gall-bladder  without 


768  TECHNIQUE    OF    OPERATIONS 

drainage.  IMayo  Robson,  even  as  late  as  1909,  still  recommended  that 
the  gall-bladder  should  be  stitched  to  the  aponeurosis  of  the  rectus  when- 
ever possible;  only  when  the  gall-bladder  is  atrophied  and  shrunken, 
and  cannot  be  brought  up  into  the  abdominal  incision  was  he  satisfied 
to  drain  it  as  we  advise  below. 

Operation. — In  most  cases  a  simple  longitudinal  incision  8  to  10  cm. 
long,  through  the  outer  third  of  the  rectus  muscle  is  sufhcient.  It  is 
wise,  particularly  in  jaundiced  cases,  to  clamp  and  ligate  all  superficial 
vessels  as  they  are  cut,  to  prevent  undue  bleeding. 

The  opening  in  the  peritoneum  is  made  large  enough  to  permit 
proper  exposure  and  manipulation  of  the  viscera.  After  the  wound 
has  been  separated  with  retractors,  the  field  of  operation  is  inspected 
and  explored  with  the  hand.  Then  a  large  gauze  pad  wrung  out  of 
hot  salt  solution  is  packed  toward  the  mid-line  walling  off  the  duodenum 
and  stomach.  A  second  pad  of  similar  character  serves  to  hold  the 
colon  and  small  intestines  out  of  the  way;  while  a  third  pad  is  placed 
in  the  subhepatic  space  or  right  kidney  pouch.  A  fourth  pad  may  be 
placed  between  the  gastro-hepatic  omentum  and  the  left  lobe  of  the 
liver,  and  a  fifth  pad  may  be  passed  up  over  the  right  lobe  of  the  liver 
to  protect  the  subphrenic  space. 

The  field  of  operation  is  thus  walled  off  from  the  rest  of  the  peri- 
toneal cavity,  and  any  leakage  of  bile  or  infective  material  will  not 
extend  to  other  parts. 

Adhesions  should  then  be  looked  for,  and  separated  if  present. 
Some  will  yield  readily  to  the  finger,  while  others  must  be  clamped, 
cut  and  ligated.  Omental  adhesions  always  should  be  clamped, 
cut  and  ligatfed,  for  fear  of  subsequent  hemorrhage. 

Now  the  gall-bladder  should  be  brought  into  the  wound,  and  if  this 
is  not  readily  done,  the  right  lobe  of  the  liver  may  be  pulled  down  and 
rotated  out  of  the  wound,  as  already  described,  to  give  a  better  exposure 
(Fig.  174).  The  gall-bladder  is  then  seized  at  the  fundus,  and  pulled 
into  the  wound  with  the  fingers,  using  a  piece  of  gauze  to  keep  the  fundus 
from  slipping  away;  if  this  cannot  be  done  with  the  fingers,  forceps 
may  be  used.     All  uncovered  surfaces  are  then  protected  with  gauze. 

If  the  condition  is  one  of  hydrops  or  empyema  of  the  gall-bladder, 
with  marked  distention  of  the  organ,  it  should  be  emptied  by  aspiration 
by  means  of  a  trocar  and  canula.  The  fluid  should  be  sent  to  the  patho- 
logical laboratory  for  culture.  The  gall-bladder  is  then  held  up  by 
means  of  forceps  and  is  opened  at  the  .fundus  with  scissors,  permitting 
the  insertion  of  the  finger.  The  interior  of  the  organ  is  then  explored 
with  the  finger,  the  general  appearance  and  condition  of  the  mucosa 


CHOLECYSTOSTOMY  769 

and  the  presence  or  absence  of  stones  are  noted.  Stones  and  inspis- 
sated bile  are  removed  by  means  of  scoop,  spoon  or  forceps.  Before 
concluding  the  operation,  unless  the  patient's  condition  is  critical,  the 
surgeon  should  examine  the  common  duct  and  the  pancreas.  During 
this  examination  the  gall-bladder  is  temporarily  plugged  with  gauze. 
To  expose  the  common  duct,  the  gall-bladder  is  pulled  upon  putting 
the  cystic  and  common  ducts  on  the  stretch.  The  cystic  and  common 
ducts  may  then  be  examined  by  sight  and  touch,  the  index-linger  of 
either  hand  being  passed  into  the  foramen  of  Winslow,  while  the  thumb 
is  placed  on  the  free  border  of  the  gastro-hepatic  ligament.  Kehr 
advised  the  surgeon  to  use  the  left  hand,  standing  with  his  back  toward 
the  patient's  head,  and  keeping  his  hand  fully  pronated  during  this 
digital  exploration  of  the  ducts;  but  usually  we  prefer  not  to  change  our 
position,  since  sight  can  be  used  as  well  as  touch.  If  a  stone  is  present 
in  the  common  duct,  it  may  be  possible  to  push  it  along  the  chole- 
dochus  into  the  duodenum;  or  it  may  be  removed  by  a  scoop  or  gall- 
stone forceps  passed  down  into  the  duct  through  the  gall-bladder  and 
cysticus,  if  the  latter  is  much  dilated.  When  these  methods  are  in- 
effective, as  they  often  are,  the  common  duct  must  be  opened  in  a  man- 
ner that  will  be  described  later  (p.  777). 

No  gall-bladder  operation  is  complete  without  examination  of  the 
common  duct  and  of  the  pancreas,  and  searching  for  enlarged  peripan- 
creatic  lymph-nodes.  At  this  stage  of  the  operation,  the  pancreas 
should  be  palpated  throughout  its  entire  length,  the  size  and  consis- 
tency of  the  organ  being  noted.  Enlarged  lymph-nodes  should  be 
looked  for,  particularly  along  the  upper  border  of  the  pancreas  (through 
the  gastro-hepatic  omentum),  at  the  junction  of  the  cystic  and  common 
ducts  and  at  the  junction  of  the  supra-  and  retroduodenal  portions  of 
the  common  duct. 

The  gauze  is  then  removed  from  within  the  gall-bladder  and  its 
interior  again  explored  with  the  linger.  The  gall-bladder  tube  with 
a  lateral  opening  near  its  end  is  then  inserted  into  the  gall-bladder  for 
a  distance  of  about  2  cm.  and  is  fastened  to  the  gall-bladder  with  a 
catgut  suture.  A  purse  string  suture  of  plain  catgut.  No.  o,  is  then 
passed  around  the  gall-bladder  about  i  cm.  from  the  opening  and  left 
untied  (Fig.  175). 

The  gall-bladder  is  then  grasped  with  tissue  forceps  at  two  opposite 

points,  below  the  purse-string  suture  and  the  tube    is    invaginated 

taking  with  it  the  edges  of  the  gall-bladder.     The  purse-string  suture 

is  then  tied.     The  advantage  of  this  procedure  is  that  a  valve-like 

closure  of  the  opening  in  the  gall-bladder  is  formed,  so  that  after  the 

tube  is  withdrawn  the  fistula  closes  rapidly. 
49 


770 


TECHNIQUE    OF    OPERATIONS 


Fig.   173. — Cholecystostomy — Above  the  Tube  is  Shown  Fixed  in  the  Gall-bladder 

by  One  Catgut  Suture,  with  the  Purse-string  Suture  Ready  to  be  Tied.  Below  at  the  Left 
the  Purse-string  has  been  Tied.  The  Diagram  at  the  Right  Shows  in  Section  the  Inversion 
of  the  Gall-bladder  Wall. 


CHOLECYSTOSTOMY 


771 


It  may  prove  impossible  to  invert  a  portion  of  the  wall  of  the-gall- 
bladder  in  the  manner  recommended,  if  the  gall-bladder  is  small  or 
has  contracted  and  thickened  walls.  Then  the  opening  in  the  gall- 
bladder should  be  sutured  as  tightly  as  possible  around  the  tube.  In 
such  cases,  or  whenever  there  is  uncertainty  as  to  the  security  of  the 
attachment  of  the  tube  to  the  gall-bladder,  it  is  safer  to  insert  also  a 
small  cigarette  or  rubber  tissue  drain  beside  the  gall-bladder,  to  provide 
an  exit  for  leakage.  This  may  be  attached  by  one  or  two  sutures  to  the 
fundus  of  the  gall-bladder  (Fig.  176).  The  gall-bladder  tube  is  made  of 
such  a  length  that  from  10  to  15  cm.  of  it  project  from  the  abdominal 
wound  or  through  a  stab  wound  made  to 
the  outer  side  of  the  former — thus  allowing 
the  abdominal  wound  to  be  closed  through- 
out. This  tube  remains  in  place  until  it 
comes  away  of  its  own  accord,  which  is 
usually  about  the  tenth  day. 

All  gauze  pads  and  sponges  are  now 
removed  from  the  abdomen,  the  gauze 
count  made  and  the  instruments  accounted 
for.  The  sand  pillow  is  removed  from 
beneath  the  patient,  as  the  closure  of  the 
wound  is  facilitated  by  its  removal.  The 
wound  is  then  sutured  from  its  upper  and 
lower  angles,  toward  the  point  of  exit  of 
the  tube  if  the  latter  is  brought  out 
through  the  wound.  The  tube  is  always 
given  exit  from  the  wound  where  it  will 
afford  best  drainage;  at  times,  as  indicated 
above,  a  counterpuncture  is  necessary  to 
insure  good  drainage.  This  depends 
largely  upon  the  size  and  position  of  the 

gall-bladder.  When  a  separate  incision  is  required  for  the  drainage 
it  usually  is  made  lateral  to  the  operation  wound,  which  may  then 
be  closed  completely. 

The  abdominal  wound  is  closed  as  recommended  at  p.  314,  a  dry 
gauze  dressing  is  apphed  and  is  held  in  place  by  strips  of  adhesive 
plaster  and  a  Scultetus  bandage.  The  dressings  are  cut  so  as  to  allow[the 
drainage  tube  to  protrude,  and  this  projecting  tube  is  then  connected 
by  a  short  piece  of  glass  tubing  to  a  long  rubber  tube  which  drains  into 
a  receptacle  at  the  bedside;  or  directly  into  a  bottle  fastened  within  the 
dressings,  which  permits  a  little  more  freedom  of  motion  in  bed. 


Fig.  176.  —  Cholecystostomy : 
Drainage  Tube  in  Gall-bladder 
and  Gauze  Ends  of  Cigarette 
Drain  Sutured  to  Fundus  of  Gall- 
bladder. 


772 


TECHNIQUE    OF    OPERATIONS 


Cholecjdiostomy  with  Prolonged  Drainage. — It  is  especially  in 
cases  of  cholangeitis,  pancreatic  13'mphangeitis,  and  chronic  interstitial 
pancreatitis,  that  this  method  is  advisable.  It  may  require  many 
months  for  the  biliary  tract  to  become  sterile. 

The  operation  differs  in  no  material  respect  from  that  of  the 
ordinary  cholecystostomy  already  described,  save  in  the  fact  that 
the  gall-bladder  is  sutured  either  to  the  parietal  peritoneum  or  the 
anterior  sheath  of  the  rectus,  and  is  not  dropped  back  into  the  ab- 
dominal cavity  after  the  margins  of  the  opening  in  its  fundus  have 
been  inverted  around  the  drainage  tube.  The  other  manipulations 
having  been  completed,  the  gall-bladder  tube  is  insefted  for  about 


Fig.  177.  —  Fundus  of  Gall-bladder 
Sutvired  to  the  Parietal  Peritoneum,  to 
Secure  Prolonged  Drainage. 


Fig.  178.  —  Fundus  of  Gall-bladder 
Sutured  to  the  Anterior  Sheath  of  the 
Rectus  Muscle,  to  Secure  very  Prolonged 
Drainage. 


2.5  cm.  into  the  opening  in  the  fundus  of  the  gall-bladder  and  is  fixed 
to  the  margins  of  this  opening  with  one  or  two  sutures  of  plain  catgut 
(No.  o).  The  opening  in  the  gall-bladder  is  then  closed  tightly  around 
the  tube,  with  sutures;  but  if  a  purse-string  suture  is  used,  no  effort 
should  be  made  to  invert  the  edges  of  the  gall-bladder  opening,  as  the 
purpose  of  the  operation  is  to  secure  prolonged  drainage  and  prompt 
closure  of  the  fistula  is  undesirable. 

When  the  abdominal  wound  is  being  closed,  the  fundus  of  the 
gall-bladder  is  caught  by  at  least  two  sutures  passing  through  the 
parietal  peritoneum  on  both  sides  of  the  abdominal  incision,  so  as 


CHOLECYSTECTOMY  773 

to  anchor  the  gall-bladder  firmly  in  the  wound  (Fig.  177).  If  very- 
prolonged  drainage  is  desired  the  gall-bladder  is  sutured  to  the  anterior 
sheath  of  the  rectus  muscle  (Fig.  178).  As  already  noted,  Mayo 
Robson,  as  late  as  1909,  still  advocated  this  method  of  treatment 
of  the  gall-bladder,  even  in  cases  of  simple  cholehthiasis,  where  pro- 
longed drainage  is  not  required;  and  he  recommended  only  in  excep- 
tional cases,  where  this  method  proved  impossible,  the  procedure 
we  have  described  as  simple  cholecystostomy — dropping  the  gall- 
bladder back  into  the  abdomen  after  closing  its  opening  around  a 
drainage  tube. 

Cholecystectomy. — In  this  operation  the  patient  is  placed  in 
the  usual  position,  the  same  incision  is  made,  and  the  parts  are 
walled  off  with  gauze  as  described.  The  best  method  of  removing 
the  gall-bladder  is  to  work  from  the  cystic  duct  and  artery  toward 
the  fundus.  This  is  preferable  to  working  in  the  opposite  direction 
in  that  the  vessels  are  clamped  and  ligated  first,  which  is  no  doubt 
the  most  important  and  at  times  the  most  difficult  part  of  the  opera- 
tion. Moreover,  when  working  from  the  fundus  downward  to  the 
duct  and  artery,  blood  from  the  denuded  surface  of  the  liver  may 
run  down  and  obscure  the  view,  and  time  is  lost  in  sponging  it  away. 

The  liver  is  pulled  down  and  rotated  out  of  the  wound,  when  this 
is  possible,  and  is  held  by  an  assistant.  The  fundus  of  the  gall-bladder 
is  drawn  taut,  and  the  pouch  of  the  gall-bladder  usually  over-hanging 
the  cystic  duct  is  caught  in  forceps  and  drawn  upward,  thus  making 
tense  the  right  border  of  the  gastro-hepatic  omentum.  The  cystic 
duct  is  next  located  and  isolated  after  making  a  small  incision  through 
the  right  free  border  of  the  gastro-hepatic  omentum,  exposing  clearly 
the  cystic  duct  at  its  junction  with  the  choledochus.  By  a  little 
gauze  or  blunt  instrumental  dissection  the  peritoneum  is  wiped  away, 
thoroughly  exposing  the  cystic  duct  and  vessels.  The  cystic  duct,  close 
to  its  termination  in  the  choledochus,  is  grasped  between  two  long- 
handled  hemostatic  forceps,  of  which  the  curved  type  proves  most  satis- 
factory for  this  purpose  (Fig.  179).  The  duct  is  then  divided  between 
the  hemostats.  Care  must  be  taken  not  to  include  a  part  of  the  wall 
of  the  common  duct;  this  is  best  avoided  by  passing  the  curved  forceps 
entirely  around  the  cystic  duct  before  clamping  it,  thus  making  certain 
that  the  wall  of  the  common  or  hepatic  duct  is  not  included  in  the 
bite  of  the  forceps.  The  cystic  artery  and  vein  which  lie  above  and 
to  the  inner  side  of  the  duct  are  then  clamped  with  two  hemostats 
and  are  divided  between  them.  At  times  it  will  also  be  necessary 
to   clamp  and  ligate  an  anomalous  branch  of  the  gastro-duodenal 


774 


TECHNIQUE    OF    OPERATIONS 


artery!  which  suppUes  the  cystic  and  common  ducts.  The  stumps 
of  the  duct  and  vessels  may  be  ligated  at  this  time,  or  if  so  desired 
not  until  the  gall-bladder  is  removed.  In  either  case  iodized  or  chromic 
catgut,  No.  2,  is  used.  It  is  a  good  plan,  before  ligating  the  stump  of 
the  cystic  duct,  to  explore  the  common  and  hepatic  ducts  as  described 
below.  When  there  is  doubt  as  to  the  need  for  drainage  through  the 
stump  of  the  cysticus,  this  may  be  clamped  by  a  hemostat,  as  suggested 
by  Ochsner  (1906);  the  hemostat  is  surrounded  by  gauze  and  rubber 


Pig.   179." 


-Cholecyatectomy— the  Common,   Cystic  and   Hepatic   Ducts  and  the  Cystic 
Artery  are  Thoroughly  Exposed. 


protective,  and  left  protruding  from  the  wound.  This  clamp  may 
be  removed  in  thirty-six  hours,  or  even  sooner  if  it  is  decided  that 
drainage  is  required.  Formal  drainage  is  described  at  page  776. 
The  method  of  draining  the  hepaticus  after  cholecystectomy  is  de- 
scribed at  page  780. 

After  the  stump  of  the  cystic  duct  and  the  cystic  vessels  have 
been  ligated,  the  separation  of  the  gall-bladder  from  its  fibrous  bed  is 
begun.  This  is  done  in  such  a  manner  as  to  preserve,  if  possible, 
that  portion  of  the  fibrous  bed  immediately  adjacent  to  the  Hver. 
By  means  of  the  finger  the  gall-bladder  is  stripped  toward  the  fundus, 


CHOLECYSTECTOMY 


775 


cutting  with  scissors  the  peritoneal  fold  when  necessary.  When  the 
separation  is  done  carefully,  there  is  very  little  if  any  bleeding  from 
the  liver  substance.  The  peritoneal  fold  is  then  closed  by  a  con- 
tinuous suture  of  iodized  catgut,  unless  the  hepatic  surface  is  infected, 
when  the  gall-bladder  bed  should  be  drained.  The  edges  of  the  opened 
gastro-hepatic  omentum  are  also  closed  by  suture  (Fig.  i8o).  In  simple 
cases  the  operation  is  now  terminated  by  closing  the  abdominal  wound 
around  a  cigarette  drain  which  extends  to  the  stump  of  the  cystic 
duct.     In  no  case  is  drainage  omitted,  as  leakage  of  bile  has  sometimes 


Fig.   i8o. — Cholecystectomy — after    Removal  of    the    Gall-bladder,    the   Gastro-hepatic 
Omentum  and  the  Bed  of  the  Gall-bladder  are  peritonized  by  Suture. 

occurred  from  slipping  or  absorption  of  the  ligature.  To  prevent  ad- 
hesions between  the  liver  and  the  pylorus  or  the  duodenum,  the 
omentum  should  be  interposed. 

In  cases  where  very  dense  adhesions  exist,  it  may  be  very  difficult 
to  identify  the  cystic  duct  before  isolating  the  gall-bladder.  Under 
such  circumstances  we  believe  the  best  technique  is  that  systematized 
by  Terrier:  The  anterior  margin  of  the  liver  is  identified,  and  the 
fundus  of  the  gall-bladder  found.  The  gall-bladder  is  then  opened 
at  its  fundus  and  its  inferior  wall  is  cut  open  little  by  little  by  snipping 
with  fine  scissors;  forceps  are  clamped  on  bleeding  points  in  the  gall- 
bladder wall.     This  incision  is  continued  into  and  through  the  cysticus, 


776  TECHNIQUE    OF    OPERATIONS 

right  down  to  the  choledochus.  This  spHtting  of  the  cystic  duct  is 
the  only  difficult  part  of  the  operation,  and  it  may  be  very  difficult. 
The  duct  cannot  be  distinguished  from  the  outside,  on  account  of 
adhesions;  and  it  is  only  recognizable  because  the  operator  cautiously 
follows  its  lumen,  much  as  one  follows  the  lumen  of  a  strictured  urethra 
in  performing  external  urethrotomy  without  a  guide.  When  the 
strictured  cystic  duct  has  been  split  all  the  way  down  to  the  choledo- 
chus, the  cystic  artery  is  ligated,  and  the  gall-bladder  and  cystic  duct 
are  removed. 

The  common  duct  and  the  hepatic  duct  are  then  explored  (by 
different  sounds,  so  as  not  to  carry  duodenal  infection  into  the  hepati- 
cus),  and  the  hepaticus  is  drained  through  the  opening  left  by  excision 
of  the  cysticus.  A  rubber  drainage  tube,  or  a  soft  rubber  catheter 
(No.  25  to  TfT,  Fr.),  open  at  the  end,  but  having  no  lateral  fenestrations, 
is  passed  up  the  hepaticus  to  its  bifurcation,  where  it  is  felt  to  be 
arrested.  The  tube  is  then  withdrawn  slightly,  and  is  stitched  in 
this  position,  with  No.  o  chromic  catgut,  to  the  stump  of  the  cysticus, 
in  such  a  way  as  not  to  diminish  the  lumen  either  of  the  duct  or  the 
tube.  The  tube  is  brought  out  of  the  abdominal  wound  at  the  most 
convenient  point;  and  should  be  carefully  distinguished  (by  color, 
by  the  insertion  of  two  safety  pins  instead  of  one,  or  in  some  other 
way)  from  any  tube  used  to  drain  the  subhepatic  space. 

In  cases  where  the  removal  of  the  gall-bladder  is  attended  with 
much  bleeding  from  the  liver  substance,  this  usually  may  be  con- 
trolled by  suturing  tightly  together  the  peritoneal  folds  which  covered 
the  gall-bladder,  thus  compressing  the  raw  surfaces  of  the  gall-bladder 
fossa.  These  sutures,  of  heavy  iodized  catgut,  should  be  passed  with 
a  large  curved  blunt  needle,  and  should  pass  into  the  liver  substance. 
At  times  a  split  rubber  tube  with  a  piece  of  gauze,  or  a  cigarette  drain 
(a  rolled  piece  of  gauze  surrounded  by  rubber  tissue),  may  be  placed 
in  the  fossa,  and  sutured  in  place  as  above  described,  thus  exerting 
sufficient  pressure  on  the  bleeding  surface  to  check  all  hemorrhage. 
These  drains  if  used  are  allowed  to  remain  until  they  come  away  easily, 
with  not  much  pulling,  which  usually  is  about  the  sixth  or  the  seventh 
day.  It  is  very  important  in  this  operation  to  control  all  bleeding 
before  closing  the  wound,  and  especially  is  this  so  in  cases  with  jaun- 
dice. Of  late  we  have  abandoned  the  use  of  the  split  rubber  tube 
carrying  a  gauze  strip  as  we  find  it  possible  to  control  the  bleeding  by 
sutures  carried  into  and  around  the  gall-bladder  bed.  In  highly  infec- 
tious cases,  however,  it  is  safer  to  drain  the  gall-bladder  bed.  And 
whenever  peritonealization  is  not  complete,  the  great  omentum  should 


CHOLECYSTECTOMY  777 

be  interposed  to  prevent  adhesions  between  the  gall-bladder  bed  and 
the  pylorus  and  duodenum. 

After  the  gauze  is  removed  from  the  abdomen  and  the  viscera 
placed  in  their  proper  position,  it  is  wise  to  place  a  rubber  tube  in 
the  subhepatic  space  or  right  kidney  well  as  far  as  the  posterior 
abdominal  wall.  This  tube  should  have  a  diameter  of  about  6  to  7  mm. 
and  should  be  fenestrated  near  its  lower  end.  The  function  of  this 
tube  is  to  drain  off  any  blood  or  bile  which  may  have  gravitated  to  this 
space  during  the  operation,  or  which  may  subsequently  collect  there. 
The  tube  is  left  projecting  from  the  abdominal  wound,  or  stab  wound, 
for  about  3  cm.  and  through  the  projecting  end  a  safety  pin  is  passed  to 
prevent  the  tube  from  falling  into  the  abdominal  cavity.  This  tube  is 
removed  thirty-six  hours  after  operation,  and  it  is  not  necessary  to 
replace  it  with  any  form  of  drainage. 

In  cases  where  there  has  been  considerable  hemorrhage  or  escape 
of  bile  into  the  subhepatic  space,  it  is  well  to  use  a  glass  drainage  tube 
instead  of  the  rubber  tube  just  advised.  This  tube  should  be  aspirated 
and  turned  every  twelve  to  twenty-four  hours  or  oftener  if  necessary, 
and  should  be  allowed  to  remain  for  thirty-six  or  forty-eight  hours, 
or  until  the  drainage  from  it  becomes  clear  and  straw  colored.  When 
this  tube  is  removed,  it  is  not  replaced  with  any  other  form  of  drainage 
except  when  the  material  drained  is  shown  by  culture  or  is  believed  to. 
be  infective;  in  which  case  a  rubber  drainage  tube  should  replace  it, 
and  this  should  be  retained  until  purulent  discharge  ceases.  When  a 
rubber  is  used  to  replace  the  glass  tube,  it  should  be  passed  down 
through  the  glass  tube  and  the  latter  removed  by  withdrawing  it 
over  the  rubber  tube. 

The  wound  after  cholecystectomy  is  closed  around  the  drain- 
age in  the  manner  which  has  been  described  in  the  previous  opera- 
tions; the  tube  which  drains  the  hepaticus  should  not  be  removed 
for  at  least  two  weeks  (page  780) ;  it  is  best  to  allow  it  to  remain  as 
long  as  it  will. 

Choledochotomy. — Strictly  speaking,  this  term  implies  merely  an 
incision  into  the  common  duct  for  the  purpose  of  removing  a  calculus 
(p.  502);  while  choledochostomy  in  its  historical  sense,  indicates  suture 
of  the  dilated  choledochus  to  the  abdominal  wound  for  the  purpose  of 
more  or  less  permanent  drainage  (p.  513).  As  the  former  operation 
(choledochotomy),  however,  almost  always  is  supplemented  by  drainage 
of  the  duct  by  tube  any  distinction  between  the  terms  choledochotomy 
and  choledochostomy  seems  a  refinement. 

These  may  be  comparatively  easy  operations  or  the  most  diflEicult 


778  TECHNIQUE    OF    OPERATIONS 

operations  in  surgery.  The  difficulties  are  due  to  strong  adhesions 
binding  the  surrounding  structures  together  into  a  mass  which  destroys 
all  anatomical  landmarks.  Especially  difficult  is  the  discovery  of  the 
choledochus  if  the  gall-bladder  and  cystic  duct  have  been  removed 
at  a  previous  operation,  since  there  is  then  no  sure  guide  to  follow.  The 
skill  of  the  surgeon  will  be  taxed  to  the  utmost  in  many  cases  where  the 
abdominal  walls  are  very  thick  and  the  liver  is  so  fixed  by  adhesions 
that  it  cannot  be  dislocated  and  brought  into  the  wound.  In  thin 
patients,  with  relaxed  abdominal  walls,  especially  women  with  movable 
liver,  and  where  no  adhesions  are  present,  rotation  of  the  liver  is  very 
easy,  and  the  common  duct  can  be  brought  up  into  the  abdominal 
incision,  permitting  all  subsequent  manipulations  to  be  carried  on 
in  full  view.  In  other  cases,  where  the  liver  is  fixed,  the  difficulties 
appear  to  be  unsurmountable,  but  they  can  be  overcome  without 
irremediable  damage  to  the  parts,  if  only  proper  carefulness  and  patience 
are  exercised,  and  the  operator  possesses  sufficient  surgical  skill. 
Excellent  illumination,  and  especially  the  Elliot  position,  do  much 
to  Lighten  the  burden  of  operating. 

Choledochotomy  when  the  Gall-bladder  is  Present. — The  usual  incision 
"is  made  through  the  abdominal  wall,  all  adhesions  are  separated,  the 
liver  is  drawn  downward  and  upward  into  the  wound  and  rotated .  After 
careful  examination  of  the  gall-bladder  and  ducts  has  been  made  for 
the  purpose  of  locating  stones  and  determining  their  presence  in  the 
common  duct,  the  gall-bladder  is  tapped  and  all  fluid  withdrawn, 
all  precautions  against  soiling  the  abdomen,  as  described  at  page  768, 
being  carefully  carried  out.  The  gall-bladder  is  then  opened  and  freed 
from  calculi  and  debris.  We  believe  that  this  step  in  the  operation 
is  advisable  in  all  cases  where  the  gall-bladder  is  distended,  with  a 
patulous  cystic  duct,  as  it  will  relieve  some  of  the  tension  in  the  common 
duct  and  prevent  excessive  escape  of  bile  from  the  choledochus  when 
this  is  incised.  The  position  of  the  calculi  in  the  common  duct  is 
then  determined  by  the  palpating  finger  which  when  passed  through 
the  foramen  of  Winslow  may  reach  almost  all  portions  of  the  duct. 
When  possible,  the  calculi  should  be  carefully  worked  backward  into 
the  supraduodenal  portion  of  the  duct,  if  they  are  found  below  this 
portion;  or  they  should  be  pushed  downward  into  it  from  the 
hepaticus,  as  the  common  duct  can  be  opened  with  most  facility  and 
safety  in  its  supraduodenal  course.  It  is  hot  an  uncommon  anomaly 
for  the  cystic  duct  to  be  inserted  at  a  very  oblique  angle,  and  very 
low  in  the  common  duct;  thus  for  some  distance  the  cystic  duct  runs 
parallel    to  the    hepatic    duct,   within   the    gastro-hepatic    omentum. 


CHOLECYSTECTOMY  779 

Trouble  may  be  experienced  in  some  cases  in  determining  the  exact 
location  of  the  common  duct  and  dstinguishing  it  from  the  portal 
vein.  We  long  ago  adopted  the  following  method  of  distinguishing 
between  the  two;  we  are  confident  it  is  safe  and  sure,  and  we  are 
pleased  to  know  that  so  skillful  an  operator  as  Terrier  employed  it  as 
a  matter  of  routine  in  difficult  cases.  The  free  border  of  the  gastro- 
hepatic  omentum  is  carefully  incised,  a  small  hypodermic  needle  is  thrust 
into  the  lumen  of  the  structure  supposed  to  be  the  common  duct,  and  the 
barrel  of  the  syringe  is  filled  with  the  contents  of  the  structure.  The 
appearance  of  the  fluid  withdrawn  will  show  at  once  whether  it  is  bile 
from  the  duct  or  blood  from  the  vein.  The  minute  puncture  immedi- 
ately closes  after  withdrawal  of  the  needle;  we  have  never  noticed 
any  leakage  from  such  a  puncture.  When  a  stone  is  present  in 
the  supraduodenal  portion  of  the  duct,  it  is  grasped  between  the 
finger  and  thumb  and  an  incision  is  made  through  the  walls  of  the 
duct,  in  the  direction  of  its  long  axis,  directly  over  the  stone,  and 
of  sufficinnt  length  to  permit  easy  removal  of  the  calculus.  The 
duct  is  carefully  explored  with  the  finger  when  the  duct  will  admit 
its  entrance,  or  with  a  probe  or  scoop  for  the  purpose  of  determin- 
ing the  presence  or  absence  of  other  stones.  When  they  are  present, 
they  should  be  pushed  toward  the  opening  in  the  duct.  When  this 
is  not  possible  they  must  be  removed  by  one  of  the  methods  de- 
scribed below.  When  the  stone  is  friable,  it  may  be  crushed  between 
the  finger  and  thumb,  the  fragments  being  extracted  with  scoop  through 
the  original  incision  in  the  duct.  This  procedure  may  cause  too  great 
trauma  to  the  walls  of  the  duct,  but  we  believe  that  crushing  with  the 
finger  and  thumb,  or  with  the  gall-stone  scoop,  if  the  proper  care  is  exer- 
cised, will  do  less  damage  and  expose  the  patient  to  less  risk  than  the 
other  methods  to  be  described.  When  the  above  procedure  will  not 
suffice,  it  may  be  possible,  by  the  aid  of  the  gall-stone  scoop,  to  push  a 
calculus  or  several  calculi  onward  into  the  duodenum. 

Thorough  exploration  of  the  hepatic  duct  must  be  made  through 
the  incision  in  the  common  duct,  the  probe  being  passed  into  each 
branch.  This  probe  should  be  perfectly  clean,  not  one  that  has  been 
passed  before  into  the  choledochus.  The  probe  or  small  scoop  should 
then  be  passed  into  the  duodenum  for  the  purpose  of  determining  the 
patency  of  that  portion  of  the  duct.  Occasionally  a  calculus  which 
cannot  be  detected  in  this  way  may  be  felt  by  a  finger  inserted  into  the 
dilated  duct.  Numerous  cases  have  been  reported  where  calculi  have 
been  left  behind,  repeated  operations  being  required  to  relieve  the  pa- 
tient of  stones  which  should  have  been  removed  at  the  first  operation. 


780  TECHNIQUE    OF   OPERATIONS 

Concretions  have  been  left  behind  by  almost  every  surgeon  who  has 
had  a  large  experience  in  gall-stone  surgery,  and  such  cases  have 
been  reported  by  Robson,  Riedel,  Kehr,  Terrier,  Fenger,  Kiister, 
Lauenstein  and  numerous  others;  and  both  of  the  present  writers 
have  committed  similar  offenses.  Unless  all  concretions  are  removed 
the  operation  will  not  afford  permanent  relief.  . 

After  the  duct  has  been  cleared  it  should  be  drained.  If  there 
are  no  gross  lesions  in  the  duct  wall,  drainage  by  a  tube  through  the 
stump  of  the  cystic  duct  is  sufiBcient,  and  the  opening  in  the  chole- 
dochus  may  be  closed  with  catgut.  When  the  duct  is  friable  or  does 
not  seem  to  be  very  healthy,  or  where  sutures  may  not  readily  be  intro- 
duced for  the  purpose  of  closing  the  opening  in  the  duct,  a  rubber  tube 
is  passed  up  into  the  hepaticus;  this  tube  is  held  in  position  with  a  small 
chromic  catgut  suture  and  the  opening  in  the  duct  is  closed  with  catgut 
sutures  around  the  drainage  tube,  thus  preventing  leakage  of  the  in- 
fectious bile  into  the  abdominal  cavity.  The  tube  in  the  choledochus 
should  be  left  in  place  until  it  comes  away  of  itself.  This  usually  is 
during  the  third  week  after  operation.  Or,  a  T-shaped  tube  may  be 
used,  one  arm  extending  toward  the  duodenal  opening  of  the  duct. 
The  latter  arm  must  not  be  so  long  as  to  extend  into  the  duodenum, 
otherwise  some  of  the  duodenal  contents  will  escape  by  way  of  the  tube, 
creating  a  duodenal  fistula.  The  T-tube  can  be  left  for  three  weeks 
or  longer,  if  thought  best.  There  is  no  difficulty  in  removing  these 
tubes  after  that  lapse  of  time — they  come  away  quite  easily. 

In  almost  every  case  of  choledochotomy,  the  gall-bladder,  when 
present,  will  have  been  opened  for  purposes  of  exploration  and  for 
the  removal  of  calcuh,  as  indicated  already.  At  the  conclusion  of 
the  operation  upon  the  common  duct,  the  gall-bladder  should  be 
drained  as  described  at  page  769  (Fig.  175);  or  if  cholecystectomy 
is  indicated  the  stump  of  the  cystic  duct  may  be  employed  for  drainage 
of  the  choledochus. 

Drainage  of  the  subhepatic  space  (page  776)  by  rubber  tube  or 
cigarette  drain  is  indicated  in  every  operation  upon  the  common 
duct. 

Choledochotomy  when  the  Gall-hladder  is  Absent. — This  usually 
is  a  difficult  operation.  A  cautious  and  lengthy  dissection  may  be 
necessary,  to  separate  adherent  stomach,  duodenum,  omentum,  or 
colon,  from  the  under  surface  of  the  liver,  and  to  enable  the  surgeon, 
finally  having  passed  these  adhesions,  to  expose  the  common  duct. 
It  is  tedious  and  difficult,  but  usually  possible  to  expose  the  supra- 
duodenal portion  of  the  choledochus  in  this  way.     When  the  common 


RETROGRADE    CATHETERISM    OF    CHOLEDOCHUS  78 1 

bile-duct  has  been  found,  it  is  opened  in  the  usual  way,  and  the  opera- 
tion concluded  as  already  described.  Desjardins  (1905)  recommended 
that  the  operator  commence  by  exposing  the  choledochus  in  the  retro- 
duodenal  portion,  by  mobilization  of  the  duodenum  (p.  784).  He  thought 
that  in  this  way  time  was  saved,  and  there  was  less  uncertainty  about 
the  position  of  important  structures.  There  are  cases  in  which  it  may 
seem  desirable  to  incise  the  duodenum  and  identify  the  choledochus 
by  retrograde  catheterization  through  the  ampulla  of  Vater  (p.  782). 
It  has  been  found  necessary  by  the  senior  author  to  employ  this  method 
only  twice  among  several  thousand  operations  on  the  biliary  tract. 
The  history  of  one  patient  was  given  at  p.  518;  that  of  the  other  is  as 
follows : 

Obliteration  of  Choledochus   Following   Cholecystectomy;   Retrograde 
Catheterism  and  Drainage.    Death 

Ella  L.,  aged  thirty-six  years,  admitted  to  the  German  Hospital,  December  1, 
1911.     Complaint,  jaundice  and  pain  in  upper  right  quadrant  of  abdomen. 

Previous  Medical  History. — Patient  always  nervous  and  never  strong.  In- 
flammatory rheumatism  at  thirteen.  Scarlatina  at  si.x.  Pleurisy  at  sixteen. 
Tonsillitis  regularly  once  a  year  up  to  fourteen  years.     Seldom  has  colds. 

Present  Illness. — Ten  to  twelve  years  ago  began  to  be  troubled  with  pressing 
sensation  in  pit  of  stomach,  distention,  belching  and  pain  in  upper  right  quadrant 
of  abdomen,  coming  on  about  three  hours  after  eating.  Sometimes  free  from  pain 
for  four  months  at  a  time. 

One  year  ago  began  to  have  attacks  of  severe  pain  in  gall-bladder  region,  radiat- 
ing to  right  shoulder,  and  sometimes  from  left  costal  margin  to  cardiac  region; 
then  sharp  pain  would  radiate  over  whole  body.  Had  four  such  attacks.  Opera- 
tion on  February  18,  1911 — cholecystectomy  for  gall-stones,  also  appendectomy. 
No  jaundice  or  sweats  before  operation;  drained  for  fourteen  weeks  following  opera- 
tion. Then  well  for  four  weeks.  Two  weeks  after  returning  home  had  a  second 
attack  of  jaundice  and  nausea.  Urine  dark,  and  since  drainage  has  stopped  skin 
has  had  light  yeUow  tinge.  Bowel  movements  eight  or  nine  times  daily.  Itching 
all  summer.  Two  weeks  ago  had  a  cold  and  cough  with  pain  in  right  hypochon- 
drium  and  costo-vertebral  angle,  not  sharp  and  not  nauseating.  No  urinarj- 
symptoms.  No  chronic  cough.  Some  pain  in  right  leg.  Condition  same  during 
last  week. 

Physical  Examination. — Poorly  nourished  female.  Marked  jaundice  of  scleras 
and  general  jaundice. 

Heart:  Muscle  sound  not  very  strong. 

Abdomen:  Distended,  slight  right-sided  rigidity.  Numbness  on  pressure 
over  mid-epigastrium.  Bimanual  palpation  reveals  large  liver,  but  whether  all  of 
tumor  mass  in  upper  right  abdomen  is  liver  cannot  be  determined. 

Operation. — Decembers,  191 1.  Common  duct  not  found;  probe  inserted  through 
stump  of  cystic  duct  passed  only  a  short  distance  and  became  obstructed;  unable 
to  find  remains  of  common  duct;  probe  passed  upward  into  hepatic  ducts  with- 
out diflSculty.     Pylorus  isolated;  intestines  walled  off  well,  the  duodenum  then 


782  TECHNIQUE  OF  OPERATIONS 

opened;  ampulla  of  Vater  found  and  probe  passed,  but  only  a  short  distance  in  the 
lower  portion  of  the  gastro-hepatic  omentum — probably  the  distal  portion  of  re- 
mains of  common  duct.  A  large  probe  now  passed  through  distal  end  of  common 
duct  into  duodenum;  stiU  larger  probe  used  in  similar  manner,  but  it  became  ob- 
structed at  ampulla.  The  ampulla  was  then  incised  and  large  probe  passed  freely. 
T-tube  inserted,  one  end  in  distal  extremity  of  common  duct  and  other  end  in 
stump  of  cystic  duct;  sutured  in  place  with  chromic  gut.  One  end  of  tube  passed 
up  through  cystic  into  hepatic  duct.  Duodenum  now  closed  with  iodine  gut 
followed  by  two  layers  of  continuous  linen.  One  spiral  tube  drain  down  to  site 
of  operation.  Wound  closed  with  chromic  gut;  two  through-and-through  silk- 
worm gut  sutures;  skin  closed  with  silk-worm  gut.     Iodine  dressing. 

Following  operation  patient  complained  of  -weakness  although  general  condition 
remained  good. 

Pulse  of  fair  volume.     Jaundice  much  improved. 

December  7,  1911. — Slight  bleeding  from  wound  which  was  readily  checked  by 
Monsel's  solution. 

December  8,  1911.— At  9.30  p.m.,  patient  vomited  500  c.c.  of  dark  grumous 
liquid — looks  like  blood.  Pulse  rapid  and  thready.  .Abdomen  soft,  no  distention. 
Fair  peristalsis.  Xo  evidence  of  peritonitis  or  obstruction.  Transfused  and 
active  stimulation  given — patient  greatly  improved.  During  the  night  patient 
vomited  bright  blood  and  expeUed  blood  per  rectum.  Origin  of  bleeding  looked  for 
but  not  discovered. 

December  9,  1911. — Died  10.20  a.m.  Wound  opened  and  stomach  found 
distended  with  yellow  fluid.  Site  of  operation  in  excellent  condition.  No  evidence 
of  peritonitis.  Mesenterj'  of  the  ileum  contained  an  ecchymosis  a  little  larger  than 
a  dollar.  Near  the  mesenteric  attachment  a  distended  blood-vessel,  apparently 
thrombotic,  stands  out  prominently.     The  small  intestines  contained  blood. 

Patient  evidently  died  as  a  result  of  the  hemorrhage  which  in  her  greatly  weak- 
ened condition  she  was  unable  to  withstand. 

Transduodenal  Choledochotomy. — This  term  is  applied  to  the 
operation  of  choledochotomy  when  the  calculus  is  removed  from 
the  choledochus  through  an  incision  made  in  the  duodenum.  The 
operation  was  first  performed  by  IMcBurney,  in  1891,  followed  by 
Kocher,  in  1895,  and  by  Mayo  Robson  in  1898.  It  is  applicable 
to  eases  of  impaction  of  a  calculus  in  the  retroduodenal,  pancreatic, 
or  interstitial  portions  of  the  common  duct.  The  interstitial  portion 
includes  the  ampulla  of  Vater,  a  dilated  portion  of  the  duct  in  which 
a  stone  may  become  lodged  and  from  which  it  can  only  with  great  diffi- 
culty be  dislodged  either  into  the  duodenum  or  back  into  the  pancreatic 
portion  of  the  duct. 

The  abdomen  is  opened  and  the  biliary  passages  liberated  from 
adhesions  and  if  possible  brought  into  the  wound  in  the  usual  manner. 
The  duodenum  and  the  terminal  portion  of  the  duct  are  raised  by  the 
fingers  of  the  left  hand,  and  the  anterior  wall  of  the  duodenum  is 


TRANSDUODENAL  CHOLEDOCHOTOMY 


783 


incised.  McBurney  advised  a  transverse  incision,  and  this  was 
employed  by  Kehr.  We  believe  that  an  incision  parallel  to  the  long 
axis  of  the  bowel  is  preferable,  as  it  gives  better  exposure  of  the  struc- 


PiG.  181. — Transduodenal  Choledochotomy.  In  the  Larger  Drawing  the  Retroduodenal 
Portion  of  the  Choledochus  has  been  Incised  over  an  Impacted  Stone  by  Means  of:  an 
Incision  in  the  Posterior  Wall  of  the  Duodenum,  Exposed  by  Opening  its  Anterior^Wall 
(Kocher's  Operation).  The  Smaller  Drawing  Shows  a  Calculus  Protruding  into  the-Du- 
odenum  from  the  Ampulla  of  Vater. 


tures  within  the  lumen  of  the  intestine  and  is  more  easily  closed  with 
less  danger  of  leakage  or  subsequent  stricture.     After  the  duodenum 


784  TECHNIQUE    OF    OPERATIONS 

has  been  opened,  the  papilla  is  to  be  located ;  if  a  stone  is  found  within 
the  ampulla  the  biliary  orifice  is  either  dilated  or  incised  upward, 
and  the  stone  removed.  When  the  stone  is  lodged  in  the  pancreatic 
or  retroduodenal  portions  of  the  duct,  the  posterior  wall  of  the  duo- 
denum may  be  incised,  thus  exposing  the  wall  of  the  choledochus; 
the  stone  is  then  removed  through  an  incision  made  into  the  duct 
directly  over  the  stone.  When  the  papilla  has  been  dilated  or  incised, 
no  attempt  is  made  to  close  the  opening.  When  the  posterior  wall 
of  the  duodenum  and  the  common  duct  have  been  incised  separately 
it  is  advisable  to  suture  the  opening  in  the  duct  to  the  incision  in 
the  posterior  wall  of  the  duodenum  in  such  a  manner  as  to  form  a 
fistula.  This  operation  was  introduced  by  Kocher  (1895)  and  is 
named  by  him  duodeno-choledockosiomy,  thus  distinguishing  it  from 
duodeno-choledochotomy,  the  operation  of  McBurney. 

The  incision  in  the  anterior  wall  of  the  duodenum  is  closed  with 
catgut,  with  a  reinforcing  suture  of  linen.  If  the  choledochus  has 
already  been  opened  in  its  supraduodenal  portion  for  the  purpose  of 
removing  a  stone,  it  should  be  drained  in  this  situation;  but  if  it  has 
been  opened  only  by  the  transduodenal  route  no  external  drainage 
of  the  duct  is  necessary.  The  operation  is  then  completed  in  the 
usual  manner. 

The  senior  author,  in  his  entire  experience,  has  been  forced  only 
twice  to  adopt  the  transduodenal  method  of  approaching  the  common 
duct  which  in  both  cases  had  been  partially  destroyed.  In  all  his  opera- 
tions for  calculus  it  has  been  possible  either  to  extract  the  stone  (entire 
or  after  breaking  it  with  the  gall-stone  scoop)  through  an  incision  in 
the  supra-duodenal  choledochus  or  to  push  the  calculus  into  the 
duodenum  by  manipulation  with  the  finger  or  the  gall-stone  scoop. 

Retroduodenal  Choledochotomy. — \\hen  a  stone  is  impacted  in 
the  retroduodenal  or  pancreatic  portions  of  the  common  duct,  and 
cannot  be  dislodged,  this  part  of  the  duct  may  be  exposed  by  mobiliza- 
tion of  the  duodenum.  The  operation  should  not  be  regarded  as  a 
substitute  for  duodeno-choledochotomy  which  should  be  reserved 
for  stones  impacted  in  the  ampulla  of  Vater  or  very  close  to  the  duode- 
nal wall.  Mobilization  of  the  duodenum  is  a  procedure  which  consists 
in  separating  the  duodenal  loop  from  its  secondarily  acquired  attach- 
ment to  the  posterior  parietal  peritoneum,  and  restoring  it  to  the 
state  in  which  it  existed  during  fetal  hfe,  with  a  distinct  mesentery 
of  its  own  (Fig.  5).  The  right  side  of  the  primitive  duodenal  mesentery 
becomes  adherent  to  the  posterior  parietal  peritoneum  overlying  the 
right  kidney;  and  in  extrauterine  life  this  adhesion  becomes  so  intimate 


RETRODUODENAL  CHOLEDOCHOTOMY 


78s 


that  no  visible  indication  exists  of  the  former  state  of  affairs.  If, 
however,  an  incision  is  made  just  to  the  right  of  the  descending  portion 
of  the  duodenum,  through  the  parietal  peritoneum  overlying  the 
right  kidney,  it  becomes  possible  by  blunt  dissection,  and  with  very 
trifling  hemorrhage,  to  separate  the  duodenum  with  its  primitive 
mesentery  (which  cajrried  the  gastro-duodenal  vessels)  from  the  original 
posterior  parietal  peritoneum,  which  covers  the  kidney  and  vena 
cava,  and  thus  to  restore  to  the  duodenum  its  former  mobility.  This 
is  the  same  principle  which  is  used  in  mobilizing  the  sigmoid  in  resection 
of  the  colon,  for  which  operation  the  method  was  introduced  by  Pierre 


Pig.  182. — Retroduodenal  Choledochotomy.  The  Presence  of  a  Stone  Impacted  in  the 
Common  Duct  having  been  Determined  by  a  Probe  Passed  from  the  Gall-bladder  or 
from  an  Incision  in  the  Supraduodenal  Choledochus,  the  Duodenum  is  Mobilized,  and 
the  Retroduodenal  Choledochus  E.xposed. 


Duval  (1902).  The  idea  of  thus  mobilizing  the  duodenum  originated 
with  Terrier,  according  to  Leriche,  and  was  described  by  his  pupil 
Jourdan  in  1895,  and  by  Vautrin  in  1896;  it  is  the  same  method  employ- 
ed by  Finney  (1902)  as  an  aid  in  his  operation  of  pyloroplasty;  and 
was  systematized  by  Kocher  in  1903,  in  connection  with  his  operation 
of  lateral  gastro-duodenostonly  (1S92)  and  his  method  of  partial 
gastrectomy.     (See  pages  330  and  351.) 

Operation. — The  operation  is  performed  thus:  after  exposing  the 
parts  through  the  usual  incision,  the  descending  duodenum  is  identified. 
An  incision  of  7  to  10  cm.  long  is  then  made  through  the  fold  of  perito- 

50 


786 


TECHXIQUE    OF    OPER.A.TIOXS 


neura  just  on  its  right  (hepato-duodenal  ligament).  Into  this  incision 
the  surgeon  inserts  his  gloved  lingers,  covered  with  gauze,  and  gently 
wipes  the  duodenum  off  the  posterior  structures,  turning  it  toward  the 
patient's  left.  As  the  peritoneal  margins  are  now  kept  under  tension, 
it  is  easy  to  extend  the  incision  upward  into  the  free  border  of  the  gastro- 
hepatic  omentum  exposing  the  common  bile-duct  at  the  first  portion 
of  the  duodenum.  From  this  point  the  choledochus  may  now  be 
traced  downward.  It  is  found  to  lie  either  in  a  groove  in  the  head  of  the 
pancreas  or  to  be  completely  buried  in  its  substance.     In  the  latter 


Pig.  I  S3. — Retroduodenal  Choledochotomy :  the  Choledochus  is  Incised  over  the  Impacted 

Calculus. 


case  V'autrin  recommends  that  it  be  exposed  by  burning  through  the 
overlying  pancreatic  tissue  with  the  actual  cautery.  Usually  it  is 
sufficient  to  expose  the  choledochus  by  blunt  dissection.  Bleed- 
ing from  the  lacerated  pancreatic  tissue  may  be  checked  by  gauze 
pressure,  or  if  persistent  by  suture.  The  calculus,  for  the  removal 
of  which  the  operation  is  done,  usually  is  palpable  through  the  pancrea- 
tic tissue  and  serves  as  a  guide  to  the  exposure  of  the  duct.  The  duct 
is  to  be  incised  directly  over  the  stone,  which  is  then  extracted  through 
the  opening  in  the  duct;  the  entire  lumen  of  the  duct  is  next  carefully 
explored  by  sound  (Fig.  184),  or  by  finger  if  the  duct  is  large  enough. 
All  obstructions  having  been  removed,  the  opening  in  the  duct  is  closed 


CHOLECYSTENTEROSTOMY 


7S7 


with  through  and  through  catgut  sutures  (or  the  sutures  may  include 
only  the  muscular  and  fibrous  coats)  around  the  tube  which  drains 
the  duct  (Fig.  185),  and  the  duodenum  is  replaced  in  its  normal  posi- 
tion, the  retroduodenal  space  being  drained  for  two  or  three  days  by  a 
rubber  tube  or  rubber  dam,  to  guard  against  possible  leakage  from 
the  choledochus.  The  abdominal  wound  is  then  closed  in  the  usual 
manner. 

We  have  never  found  it  necessary  to  expose  the  common  duct  in  this 
manner. 


Pig.  184. — Retroduodenal  Choledochotomy :  after  Removal  of  the  Stone,  the  Hepatic  Duct 

is  Explored  by  Probe. 

Cholecystenterostomy. — This  is  an  operation  for  the  establish- 
ment of  a  iistula  between  the  gall-bladder  and  a  portion  of  the  intestinal 
tract.  The  duodenum  should  be  selected  for  the  anastomosis  when 
possible;  such  an  operation  is  termed  a  cholecysto-duode-n ostomy.  If 
the  jejunum  is  used,  it  is  called  cholecysto-jejunostomy.  Anastomosis 
with  the  colon  is  known  as  a  cholecysto-col ostomy.  We  have  already 
(page  515)  expressed  our  preference  for  an  anastomosis  with  the  stomach 
{cholecysto-gastrostomy)  whenever  the  duodenum  is  not  accessible.  The 
indications  and  contra-indications  to  cholecystenterostomy  have  also 
been  discussed  at  pages  681  and  702. 

The  anastomosis  may  be  made  by  direct  suture,  or  by  means  of  a  small 
Murphy  button  (Fig.  186)  or  a  Robson  bobbin.     These  methods  slightly 


788 


TECHNIQUE    OF    OPERATIONS 


shorten  the  time  of  operation  and  are  more  easily  performed  than  the 
direct  suture  method,  but  we  prefer  the  latter  because  we  feel  more  sure 
of  the  firmness  of  the  resulting  union  of  the  two  viscera.  The  union 
when  the  button  is  used  is  very  slight  immediately  following  the  slough- 
ing of  the  tissues  crushed  between  the  two  portions  of  the  button  and, 
as  stated  by  Robson,  it  is  necessary  to  keep  the  patient  absolutely 
quiet  for  two  weeks  before  one  can  rest  assured  that  the  union  will  not 
break  down  and  allow  escape  of  the  visceral  contents. 


Pig.  185. — Retroduodenal  Choledochotomy :  Drainage  of  the  Choledochus  and  of  the  Gall- 
bladder by  Separate  Tubes. 

The  abdomen  is  opened  in  the  usual  manner  for  exposure  of  the 
biliary  passages,  and  the  operative  field  within  the  abdomen  is  cleared 
of  viscera  and  walled  off  as  previously  described.  The  gall-bladder  is 
opened  at  its  fundus,  and  is  emptied  of  calculi,  bile  or  debris.  The  use 
of  a  small  pair  of  anastomosis  forceps  with  rubber-covered  blades 
considerably  facilitates  the  insertion  of  the  sutures,  but  it  is  not  always 
possible  to  free  the  structures  sufficiently  for  their  application,  even 
when  one  adopts  the  method  of  mobilizing  the  duodenum,  already 
described  (page  784).  Whenever  possible,  a  lateral  anastomosis  is  made 
by  suture,  as  detailed  at  page  335.  The  opening  in  the  duodenum  is 
about  2.5  cm.  in  length,  corresponding  in  size  to  that  made  in  the 
gall-bladder.  The  anastomosis  should  be  carefully  inspected  for  s'gns 
of  leakage.     The  abdominal  wound  may  be  closed  without  drainage  but 


CHOLECYSTENTEROSTOMY 


789 


it  is  safer  to  leave  a  piece  of  rubber  tissue  as  a  drain  to  the  site  of 
the  anastomosis. 

When  the  Murphy  button  is  used  instead  of  the  suture  method, 
a  small  sized  button  is  selected.  The  opening  in  the  gall-bladder 
is  encircled  by  a  running  suture  of  hnen.  The  portion  of  duodenum 
or  stomach  to  be  used  in  the  anastomosis  is  freed  of  its  contents  by 
gentle   stroking,    and   clamps   with    rubber-covered   blades   then   are 


Pig.  186. — Cholecysto-duodenostomy  by  Means  of  a  Murphy  Button. 


applied  for  the  purpose  of  preventing  any  discharge  from  the  gut 
during  the  succeeding  steps  of  the  operation.  A  circular  suture  of 
linen  thread  is  then  run  around  the  site  of  the  proposed  opening  in  the 
bowel,  and  the  latter  is  incised  just  enough  to  permit  the  introduction 
of  one  end  of  the  button.  The  suture  is  drawn  tight  around  the  central 
barrel  of  the  button,  and  the  second  part  of  the  button  is  fastened  into 
the  opening  in  the  gall-bladder  in  a  similar  manner.     The  two  ends  of 


790  TECHNIQUE    OF    OPERATIONS 

the  button  are  approximated  and  pushed  together  firmly.  Then  it  is 
well  to  apply  a  few  interrupted  sero-serous  sutures  to  hold  the  viscera  in 
apposition,  and  relieve  the  strain  on  the  anastomosis.  This  com- 
pletes the  operation,  and  the  abdominal  wound  often  may  be  closed 
without  drainage. 

Other  methods  of  biliary  intestinal  anastomosis,  such  as  choledocho- 
enterostomy,  hepatico-enterostomy,  etc.,  have  been  discussed  at 
page  sio. 

()PER.A.TIONS    ON   THE   LlVER 

Hepatopexy. — This  is  an  operation  to  fix  a  movable  liver.  It  is 
very  seldom  required.  Fixation  is  best  secured  by  attaching  the 
anterior  margin  of  the  liver,  particularly  the  right  lobe,  to  the  costal 
margin  by  means  of  heavy  sutures  of  chromic  catgut.  The  greater  the 
number  of  the  sutures,  the  less  will  be  the  strain  on  any  one  of  them. 

Operation. — The  abdomen  is  opened  by  the  incision  usually  em- 
ployed for  operations  on  the  biliary  tract,  and  the  proptosed  liver  is 
replaced  in  its  normal  position.  If  it  is  irreducible,  it  should  be  fixed 
in  the  best  obtainable  position  by  means  of  sutures  passed  through  the 
muscular  and  aponeurotic  structures  of  the  anterior  abdominal  wall. 
When  it  has  been  returned  to  its  normal  site,  the  skin  and  subcut- 
aneous tissues  should  be  dissected  back  over  the  costal  margin  until 
this  is  fully  exposed.  Then  a  strong  round  needle,  with  large  curve, 
and  armed  with  No.  2  or  No.  3  chromic  catgut,  should  be  passed  from 
above  through  the  costal  margin,  between  the  costal  cartilages,  directly 
through  the  costophrenic  structures,  emerging  in  the  peritoneal  cavity 
close  to  the  anterior  margin  of  the  liver.  This  is  then  penetrated  from 
above  downward,  and  when  the  needle  has  been  withdrawn  from 
the  under  surface  of  the  liver,  it  is  at  once  carried  back  again  to  a 
point  about  half  a  centimetre  distant  from  its  original  place  of  en- 
trance, thus  completing  one  mattress  suture.  From  two  to  eight 
such  sutures  should  be  passed.  Injury  of  the  pleura  has  occurred 
but  has  caused  no  harm.  The  knots  of  the  sutures  thus  are  placed 
on  the  superficial  surface  of  the  thorax,  just  beneath  the  subcutaneous 
fat.  All  the  sutures  should  be  placed  before  any  one  of  them  is  tied; 
and  just  before  they  are  tied  the  convex  surface  of  the  liver  and  the 
under  surface  of  the  diaphragm  should  be  abraded  with  gauze  so  as  to 
promote  adhesion.  The  abdominal  incision  is  closed  without  drain- 
age.    The  patient  should  remain  recumbent  for  three  weeks. 


TRANSPLEURAL   HEPATOTOMY   FOR   ABSCESS 


791 


Depage's  operation  (1904)  includes,  in  addition  to  hepatopexy  by  a 
modified  technique,  also  a  rather  extensive  excision  of  the  abdominal  wall 
(lapareciomy) ,  as  he  regards  laxity  of  the  abdominal  wall  as  one  of  the 
main  causes  of  visceral  prolapse.  The  excision  involves  the  whole  of 
the  linea  alba,  and  a  more  extensive  area  of  the  overlying  skin  and  fat. 
By  careful  suturing  of  the  anterior  and  posterior  sheaths,  the  two  recti 
muscles  (formerly  widely  separated  by  the  thinned  and  stretched 
linea  alba)  are  brought  together  in  the  median  hne,  and  the  umbihcal 
and  falciform  ligaments  of  the  liver  are  drawn  taut  and  fixed  in  the 
upper  angle  of  the  wound. 

Other  methods  of  hepatopexy   have  been  referred  to  at  page  539. 

Transpleural  Hepatotomy  for  Ab- 
scess of  the  Liver. — A  10  cm.  sub- 
periosteal resection  of  the  eighth, 
ninth  or  tenth  rib  (according  to  the 
site  of  the  abscess)  is  done,  in  the 
mid-axillary  line.  It  is  better  to  excise 
a  rib  that  is  too  low  than  one  that  is 
too  high  (Fig.  187).  If  it  is  thought 
necessary  to  remove  also  a  portion  of 
the  next  rib  above,  this  may  be  done 
at  the  same  time,  or  later.  Both  ribs 
may  be  exposed  by  an  incision  over 
the  intervening  intercostal  space;  or, 
if  preferred,  a  flap  of  the  soft  parts 
may  be  turned  up,  exposing  two  or 
three  ribs.  To  avoid  infection  of  the 
pleura  the  surgeon  should  next  in- 
sert, along  the  lower  border  of  the 
highest  rib  exposed,  three  or  four  in- 
terrupted sutures  of  chromicized  cat-  inrMe\hl^t^AppTfJhA^7JsCo7o. 
gut  which  include  the  deep  layer  phrenic  sinus. 
of  the  periosteum,  both  layers  (parietal  and  diaphragmatic)  of  the  mw- 
opened  pleura,  and  the  diaphragm  (Fig.  188).  This  plan,  employed  by 
W.  W.  Ashhurst  (1905),  and  advocated  by  Korte  (1912),  is  much  safer 
than  trusting  to  inward  pressure  to  hold  the  pleura  in  contact  with  the 
diaphragm,  or  than  relying  on  clamps  for  the  same  purpose,  or  even 
than  suturing  the  two  layers  of  the  pleura  together  after  the  pleura  has 
been  opened,  as  was  originally  done  by  Knowsley  Thornton  (1886). 
W.  W.  Ashhurst,  who  had  a  large  experience  with  operations  for  hepatic 
abscess  during  his  residence  in  Mexico,  pointed  out  that  it  is  easy 


792 


TECHNIQUE    OF    OPERATIONS 


to  tell  by  the  sense  of  touch  when  the  needle  catches  in  the  diaphragm, 
and  that  it  is  unnecessary  to  insert  these  sutures  anywhere  except  as 
advised,  above  the  site  proposed  for  the  incision  through  the  layers  of  the 
pleura  and  the  diaphragm.     According  to  Korte,  Roux  recommends 


Pig.  1 88. — Transpleural  Operation  for  Hepatic  Abscess:  Sutures  Passing  through 
Deep  Layer  of  Costal  Periosteum,  both  Layers  of  Unopened  Pleura,  and  Underlying 
Diaphragm. 

that  these  sutures  be  inserted  so  that  each  one  interlocks  with  the  next. 
Having  thus  shut  off  the  pleural  cavity,  an  incision  is  then  made 
along  the  upper  border  of  the  lowest  rib  exposed  (Fig.  189).  This 
incision  divides  the  deep  layer  of  the  periosteum,  and  both  layers  of  the 
pleura  in  the  costophrenic  sinus.     The  diaphragm  is  next  incised;  this 


Fig.    189. — Transpleural  Operation    for  Hepatic  Abscess:  Incision  Across  Costo-phrenic 

Sinus. 


may  be  done  in  the  same  direction  as  the  former  incision,  or  at  right 
angles  to  it,  splitting  the  diaphragmatic  fibres  parallel  to  their  course. 
The  right  lobe  of  the  liver  may  now  be  freely  palpated.  The  liver,  in 
acute  cases,  is  bluish,  soft  and  pulpy,  and  often  bulges  into  the  wound. 


PARTIAL   HEPATECTOMY   FOR    TUMOR  793 

The  region  of  the  abscess  is  more  resistant  to  palpation,  and  usually 
is  indicated  by  denser  adhesions.  Gauze  should  be  packed  around  the 
site  proposed  for  the  incision  into  the  liver,  and  if  the  finger  does  not 
break  into  the  abscess  cavity,  an  exploring  needle  or  grooved  director 
should  be  pushed  into  the  liver.  If  more  room  is  needed  another  rib 
(the  next  higher)  may  be  excised,  but  it  is  not  necessary  to  enlarge  the 
opening  in  the  pleura.  When  pus  is  located,  an  incision  into  the  ab- 
scess cavity  should  be  made  along  the  needle  or  director  as  guide. 
For  this  incision  a  bistoury  is  preferable  to  the  actual  cautery  advised 
by  some  surgeons.  A  free  opening  for  drainage  should  be  secured  by 
dilating  the  incision  with  the  finger  or  dressing  forceps.  Search  should 
be  made  for  neighboring  abscesses,  which  should  be  opened,  if  possible, 
through  the  walls  of  the  first  abscess  incised. 

Drainage  is  to  be  secured  by  placing  two  large  rubber  tubes  into  the 
abscess  cavity.  The  remainder  of  the  wound  is  then  tamponed  with 
gauze. 

After-treatment. — Irrigation  should  not  be  practised  for  four  or 
five  days  at  the  least.  It  is  facilitated  by  the  use  of  a  double  tube  for 
drainage,  as  already  advised.  These  tubes  may  be  shortened  from 
day  to  day,  but  not  too  rapidly.  The  sinus  may  take  many  weeks  to 
close. 

Appendicostomy  may  be  necessary  if  the  colitis  persists. 

Hepatotomy  for  hydatid  cysts  has  been  described  at  page  567. 

Hepatorrhaphy,  or  suture  of  the  liver,  is  described  below,  in  connec- 
tion with  hepatectomy. 

Hepatectomy. — In  removing  portions  of  the  liver  the  main  problem 
is  control  of  hemorrhage  during  the  operation.  The  method  proposed  by 
Pringle  (mentioned  at  page  600),  which  consists  in  clamping  the  pedicle 
of  the  liver,  has  not  been  adopted  in  the  human  subject,  so  far  as  we 
know.  McDill  (1912)  thinks  the  forceps  could  be  kept  in  place  for 
fifteen  or  twenty  minutes  without  doing  permanent  damage. 

If  the  tumor  to  be  excised  possesses  a  small  pedicle,  which  does  not 
itself  require  excision,  this  may  be  clamped  by  crushing  forceps.  Kocher 
prefers  the  use  of  very  heavy  crushing  forceps  which  will  squeeze  all  the 
parenchymatous  tissue  away  from  the  line  of  compression,  leaving  only 
the  capsule  of  Glisson,  which  may  be  easily  sutured.  Freeman  (1919) 
describes  a  case  in  which  he  removed  a  cancer  of  the  right  lobe  of  the 
liver,  involving  the  gall-bladder  and  transverse  colon  in  one  mass; 
after  determining  that  the  growth  was  apparently  primary  and  that  no 
enlarged  lymphnodes  could  be  found,  he  determined  to  remoye  it 
en  bloc,  together  with  the  cecum,  the  ascending  colon  and  half  of  the 


794 


TECHNIQUE    OF   OPERATIONS 


transverse  colon.  (The  patient  recovered  but  developed  recurrence 
within  six  months.)  The  method  of  control  of  bleeding  from  the  liver 
was  simple  and  efl&cient: 

"In  order  to  get  well  beyond  the  tumor  it  was  necessary  to  resect 
a  large  portion  of  the  right  lobe  of  the  liver,  the  Une  of  incision  passing 
through  the  entire  thickness  of  the  organ.  Hemorrhage  was  controlled 
by  tying  off  the  part  to  be  removed  by  means  of  two  long  narrow  strips 
of  fascia  lata,  like  pieces  of  tape.     These  strips  were  first  pulled  directly 


Fig.  190. — Freeman's  Method  o£  Resection  of  the  Liver.     (See  Text.) 

through  the  substance  of  the  liver,  from  behind  forwards,  with  a  pair 
of  long  alligator  forceps,  and  their  respective  ends  tied  very  tightly 
around  the  hepatic  substance  to  either  side,  much  as  one  would  transfix 
and  tie  off  the  pedicle  of  an  ovarian  tumor  (Fig.  190).  (The  presence  of 
the  fascia  soon  checks  any  bleeding  which  may  occur  from  the  sides  of 
the  hole  through  which  it  is  pulled,  provided  the  opening  is  not  too 
large;  hence  the  importance  of  using  alligator  forceps,  or  at  least  those 
which  are  long  and  narrow.)  The  growth  was  then  cut  away,  well 
within  healthy  liver  tissue,  without  the  slightest  difiiculty  or  bleeding, 
in  spite  of  the  great  thickness  of  the  hepatic  stump." 


CEPHALIC   PANCREATECTOMY 


795 


Whatever  the  method  of  temporary  hemostasis  adopted,  it  is  well 
to  make  the  section  of  the  hver  in  wedge  shape,  so  as  to  facilitate 
closure  of  the  wound  (Fig.  191).  When  the  tumor  has  been  removed, 
the  sectioned  area  requires  treatment,  for  the  permanent  arrest  of 
hemorrhage  and  oozing  of  bile.  Ligation  of  the  larger  individual 
vessels  should  be  done  whenever  possible. 

Suture  of  the  liver  is  difficult  only  because  the  usual  suture  material 
as  ordinarily  applied  is  prone  to  tear  out.  The  needles  employed 
should  be  long,  rather  blunt  pointed,  and  without  any  cutting  edge. 
For  experimental  work  J.  E.  Sweet  has  devised  a  needle  with  a  female 
thread  at  one  end,  instead  of  an  eye;  dry  catgut  is  screwed  into  this. 
This  plan  avoids  the  "shoulder"  formed  where  the  catgut  is  doubled 
to  pass  through  the  eye  of  the  ordinary  needle.  Sweet  thinks  this 
needle  minimizes  the  traumatism  to  the  liver.  Heavy  chromicized 
catgut  (No.  2  or  3)  is  the  best  material  for  the  sutures,  which  should 
be  introduced  as  mattress  sutures.     They  should  be  tied  over  a  number 


Pig.  191. — Suture  of  Wedge-shaped  Wound  of  Liver,  Left  after  Resection  of  a  Tumor.     The 
Mattress  Sutures  are  Tied  over  Strands  of  Catgut  to  Prevent  them  from  Cutting  out. 

of  strands  of  catgut,  or  a  strip  of  fascia,  cut  from  the  abdominal 
aponeurosis,  according  to  the  principle  of  the  old  fashioned  "quilled 
suture"  (Fig.  191).  This  plan  prevents  the  sutures  from  cutting  out 
when  they  are  pulled  tight,  and  makes  them  efficient  in  checking 
hemorrhage.  Finally  the  free  margins  of  the  liver  flaps  should  be 
united  with  a  continuous  suture  of  chromic  catgut  No.  i. 

In  all  cases  drainage  of  the  abdomen  is  advisable  to  provide  for 
leakage  of  blood  or  bile. 

Operations  on  the  Pancreas 

.  Pancreatotomy  for  cysts,  etc.,  has  been  described  at  page  714. 

Pancreatostomy,  according  to  the  method  of  Link,  is  described 
at  page  687. 

Pancreatectomy. — We. have  already  discussed  resection  of  the 
body  of  the  pancreas,  and  excision  of  its  tail  (page  701) ;  and  it  remains 


796 


TECHNIQUE    OF    OPERATIONS 


for  US  here  to  describe  the  technique  employed  for  excision  of  the 
head  of  the  pancreas,  or  total  cephalic  pancreatectomy,  as  it  is  termed 
by  Sauve  (1908). 

The  chief  indications  are  carcinoma  of  the  head  of  the  pancreas 
or  of  the  ampulla  of  Vater  invading  the  pancreas.  As  extension 
to  the  duodenum  from  the  pancreas,  and  to  the  pancreas  from  the 
papilla  of  Vater  or  elsewhere  in  the  duodenum  occurs  very  early,  the 
complete  removal  of  a  tumor  in  either  situation  usually  involves 
pyloro-duodeno-pancreatectomy.  The  duodenum,  it  is  true,  may  be  re- 
moved without  impairing  the  blood-supply  of  the  pancreas  (p.  367),  as 
pointed  out  by  Cotte  and  Maurizot  (1910);  but  the  reverse  is  not 
true.     Removal  of  the  head  of  the  pancreas  requires  also  removal 

of  the  surrounding  duodenum,  be- 
cause the  blood-supply  of  the  latter 
is  necessarily  destroyed. 

Early  diagnosis  is  necessary  to 
render  such  an  operation  of  any 
value;  but  as  noted  at  page  699  the 
classical  signs  of  cancer  of  the  pan- 
creas usually  are  evidences  of  inoper- 
able growths. 

Operation. — Very  free  exposure  is 
required.  The  incision  recommended 
by  Desjardins  (1907)  is  shown  in  Fig. 
192.  A  long  paramedian  incision,  or 
the  Czerny  incision  probably  would 
do  as  well  (page  763). 

According  to  the  technique  elabo- 
rated by  Sauve  the  operation  com- 
prises the  following  steps:  (i) 
Abdominal  incision.  (2)  Ligation  of  the  pyloric  and  gastro-duodenal 
arteries  and  section  of  the  pylorus.  (3)  Mobihzation  of  the  duode- 
num. (4)  Section  of  the  transverse  duodenum,  just  to  the  right  of 
the  superior  mesenteric  vessels.  (5)  Separation  of  the  so-called  "little 
pancreas"  from  beneath  the  superior  mesenteric  vessels,  and  of  the  head 
of  the  pancreas  from  the  portal  vein.  (6)  Section  of  the  head  from 
the  tail  of  the  pancreas;  second  ligation  of  the  gastro-duodenal  artery; 
ligation  and  section  of  the  choledochus. 

These  steps  terminate  the  operation  of  duodeno-pancreatectomy 
proper,  but  there  still  remain  to  be  done  the  supplementary  operations 
of   gastro-enterostomy   and   cholecystenterostomy   or   some   of    their 


Pig.    192. — Incision  for  Total  Cephalic 
Pancreatectomy.     (Desjardins.) 


CEPHALIC   PANCREATECTOMY 


797 


modifications.  Finally,  some  disposition  must  be  made  of  the  sec- 
tioned tail  of  the  pancreas.  Sauve  advises  fixing  this  in  the  abdominal 
wound  by  a  method  of  pancreatostomy  somewhat  analogous  to  that 
employed  by  Link  (page  687).  Desjardins  suggested  that  it  be  im- 
planted into  a  loop  of  jejunum;  and  by  means  of  Coffey's  (1909) 
proposed  technique  for  pancreato-enterostomy,  which  was  successful  in 
dogs,  this  disposition  of  the  pancreatic  stump  might  be  safely  accom- 
plished in  life. 


■■> 


.■■■■  ^ 
Common  Bile  Duct     .■'  ^ 


Pig.  193. — Pancreato-enterostomy.  After  Duodeno-pancreatectomy,  the  Body  of  the 
Pancreas  is  Implanted  into  the  Apex  of  a  Loop  of  Jejunum.  The  Jejunum  is  Anastomosed 
with  the  Pylorus,  and  the  Choledochus  is  Implanted  in  it  Just  Distal  to  this  Anastomosis. 
{Coffey.) 

This  operation  of  duodeno-pancreatectomy  is  so  extensive  and 
requires  so  long  a  time  for  its  performance  that  it  probably  would  be 
better  to  perform  it  in  two  stages.  As  the  most  urgent  symptom 
usually  is  the  presence  of  obstructive  jaundice,  the  first  operation 
might  be  planned  to  relieve  this  by  some  form  of  biliary  and  intestinal 
anastomosis;  but  the  extremely  unfavorable  prognosis  which  attends 


798 


TECHNIQUE    OF    OPERATIONS 


such  operations  for  malignant  obstruction  renders  their  employment 
hazardous.  It  seems  probable,  therefore,  that  the  radical  operations 
for  carcinoma  of  the  head  of  the  pancreas  could  be  indicated  only 
when  the  condition  was  found  unexpectedly  when  operating  upon 
a  fairly  healthy  patient.  Under  such  circumstances  it  would  be 
proper,  we  believe,  to  perform  at  the  first  operation  posterior  gastro- 
jejunostomy and  exclusion  oj  the  pylorus  (page  ii6);  at  the  second 
operation,  two  weeks  or  more  later,  duodeno-pancreatectomy  may 
be   attempted,   and  in  cases  of  emergency  the  bile  and  pancreatic 


Fig.  194. — Pancreato-enterostomy.  As  a  Palliative  Operation  the  Tail  of  the  Pan- 
creas may  be  Implanted  into  the  Apex  of  a  Jejunal  Loop.  A  Jejuno-jejunostomy  is 
Also  Done.     (Coffey.) 

juice  might  be  drained  externally  for  a  time,  and  the  supplementary 
operations  of  cholecyst-  (choledocho-)  enterostomy  and  pancreato- 
enterostomy be  postponed  to  a  third  intervention.  These  latter 
operations  if  done  at  the  first  sitting  would  obscure  the  operative 
field  so  as  to  render  duodeno-pancreatectomy  impracticable. 

Though  such  extensive  operations  on  patients  so  gravely  ill  seem 
to  offer  little  prospect  even  of  immediate  survival,  and  still  less  of  ulti- 
mate cure,  it  should  not  be  overlooked,  as  Sauve  has  pointed  out. 


SPLENECTOMY  799 

that  even  in  unpremediated  pancreatectomies,  done  without  a  well- 
ordered  technique,  and  with  no  previous  experience,  the  successes  have 
been  more  numerous  than  the  failures  (9  recoveries  among  1 6  operations) . 
Sauve  concluded  that  when  the  surgeon  should  become  possessed  of^a 
carefully  ordered  technique  for  total  excision  of  the  head  of  the  pan- 
creas, and  when  he  should  have  clearly  recognized  the  indications  for 
the  operation,  that  then  the  successes  would  be  more  numerous,  and 
above  all  more  lasting. 

Pancreato-enterostomy.- — Desjardins,  as  already  mentioned,  pro- 
posed to  implant  the  sectioned  end  of  the  pancreas  into  the  intes- 
tinal canal.  The  technique  of  the  operation  has  been  worked  out  by 
Coffey  (1909)  in  experiments  on  dogs.  He  found  end-to-end  anas- 
tomosis was  preferable  to  end-to-side  implantation.  After  section  of 
the  Jejunum,  the  continuity  of  the  intestinal  tract  is  restored  by  implant- 
ing the  upper  jejunal  loop  into  the  side  of  the  lower  (Y-anastomosis) ; 
the  open  end  of  the  aboral  segment  of  jejunum  is  then  employed 
for  the  reception  of  the  sectioned  pancreas.  Coffey  found,  however, 
that  the  lumen  of  the  bowel  was  not  sufficiently  capacious  to  permit 
of  the  intestinal  wall  being  inverted  around  the  stump  of  the  pancreas 
after  the  latter  had  been  introduced  into  the  bowel.  He  therefore 
adopted  the  method  of  throwing  the  lumina  of  two  intestines  into  one  by 
making  his  opening  in  the  bowel  at  the  apex  of  a  loop  (Fig.  193).  In  this 
way  it  was  possible  to  obtain  a  very  secure  anastomosis.  As  a  pallia- 
tive operation,  Coffey  suggested  implating  the  tail  of  the  pancreas 
into  the  intestine,  thus  permitting  reverse  drainage  of  the  obstructed 
pancreatic  duct  (Fig.  194). 

Operations  on  the  Spleen 

Splenectomy. 

Incision. — In  traumatic  cases  the  best  incision  is  a  longitudinal 
one  above  the  umbilicus  to  the  left  of  the  median  line,  as  it  enables  the 
operator  to  examine  the  other  viscera.  If  difficulty  is  experienced  in 
exposing  a  spleen  which  is  fixed  by  adhesions,  the  left  rectus  muscle 
should  be  divided  transversely,  as  in  Czerny's  similar  incision  on  the 
right  side  for  difficult  operations  on  the  bile-ducts.  In  other  cases, 
an  incision  through  the  outer  border  of  the  left  rectus,  continued, 
if  necessary,  up  the  rib  margin  to  the  ensiform  cartilage  gives  read- 
iest access  to  the  spleen.  This  is  similar  to  Mayo  Robson's  inci- 
sion on  the  patient's  right,  for  operations  on  the  biliary  tract.  Some- 
times it  is  easier  to  reach  the  pedicle  of  the  spleen  from  the  inner  side 
through  a  median  incision,  but  usually  an  incision  through  the  left 
rectus  near  its  outer  border  is  the  most  satisfactory. 


8oo 


TECHNIQUE    OF    OPERATIONS 


The  abdomen  having  been  opened,  the  future  steps  of  the  opera- 
tion depend  on  the  presence  or  absence  of  adhesions.  The  latter 
usually  are  most  numerous  between  the  diaphragm  and  the  upper 
pole  of  the  spleen  although  omental  adhesions  are  not  uncommon. 
Before  proceeding  further,  the  splenic  region  should  be  isolated  by 
gauze  pads. 


Fig.   195. — Exposure  of  the  Splenic  Pedicle  through  the  Gastro-splenic  Ligament,  after 
Drawing  the  Stomach  Down  and  Well  Toward  the  Patient's    Right. 

The  most  important  part  of  the  whole  operation  is  the  control 
0}  hemorrhage.  The  capsule  of  the  spleen  is  easily  torn  and  the  pulp 
is  soft  and  friable.  The  walls  of  the  veins  in  the  pedicle  are  thin 
and  tear  readily  or  else  are  calcareous  and  brittle.  Gentle  mani- 
pulation therefore  is  necessary. 


SPLENECTOMY 


80 1 


In  cases  where  the  spleen  is  not  too  large,  it  may  be  possible  to 
expose  its  pedicle  from  the  front  (Fig.  195),  after  drawing  the  stomach 
far  to  the  right  and  dividing  the  gastrosplenic  omentum  and  its  con- 
tained vessels:  the  vasa  brevia  to  the  stomach  and  the  left  gastro- 
epiploic vessels  (Fig.  196).  Occasionally  the  left  gastro-epiploic  arises 
from  the  splenic  artery  sufficiently  proximal  to  the  entrance  of  the 


Fig.  196. — Diagram  to  Show  Splenic  Pedicle — Transverse  Section  at  Level  of  Splenic 
Artery.  Note  the  left  Gastro-epiploic  Artery  (Branch  of  Splenic)  in  the  Gastro-splenic 
Ligament. 

latter  into  the  spleen  as  to  render  it  unnecessary  to  divide  the  former 
to  expose  the  splenic  pedicle. 

In  traumatic  cases,  the  splenic  artery  may  be  exposed  through 
the  gastro-hepatic  omentum  (Fig.  197),  and  clamped  or  ligated  in  this 
situation,  before  the  spleen  is  directly  attacked.  In  most  cases,  how- 
ever, the  vessels  in  the  pedicle  can  be  more  easily  reached  if  the  spleen 
is  turned  over,  but  this  is  not  possible  until  the  adhesions  are  broken 
down,  and  the  lienophrenic  fold  of  peritoneum  divided.  These  ad- 
hesions may  not  only  be  very  dense,  but  may  contain  very  large  veins 
which  are  easily  ruptured.  Hence  it  is  well  whenever  possible,  to 
divide  the  resistant  adhesions  between  two  clamps,  and  as  the  spleen 
is  gradually  mobilized,  to  pack  a  large  hot  moist  gauze  pad  into  the 
bed  from  which  the  spleen  has  been  raised.     This  pack  will  control 


802 


TECHNIQUE  OF  OPERATIONS 


minor  venous  oozing.  When  the  hand  can  be  introduced  finally 
between  the  spleen  and  diaphragm,  the  former  may  be  drawn  down  into 
the  wound.  It  then  can  be  turned  over,  and  the  vessels  in  the  pedicle 
may  be  isolated  by  blunt  dissection  (Fig.  198).  If  they  are  not  too 
large  they  may  be  secured  in  two  long  clamps  which  should  be  applied 
as  close  as  possible  to  the  spleen;  the  pedicle  may  then  be  cut  between 


Fig.    197. — Exposure  of  the  Splenic  Vessels  by  an   Incision  through  the  Gastro-hepatic 
Omentum.     Note  the  Celiac  Axis  Showing  through  the  Posterior  Parietal  Peritoneum. 

them  and  the  spleen  and  the  ligatures  applied  in  the  groove  made  by 
the  deeper  clamp  before  the  other  clamp  is  removed.  In  three  out  of 
thirty-one  splenectomies,  Mayo  injured  the  pancreas,  and  had  to  in- 
clude its  stump  in  his  ligatures.  All  three  patients  recovered.  There 
must  be  enough  tissue  left  in  the  pedicle  to  admit  of  the  safe  appli- 
cation of  ligatures  and  whenever  possible  each  vessel  that  can  be 
identified  should  be  Hgated  separately  as  it  projects  from  the  clamps 
after  the  spleen  has  been  cut  away;  these  ligatures  are  in  addition 


SPLENOTOMY 


803 


to  any  ligature  used  to  transfix  the  pedicle  or  to  ligate  it  in  sections 
on  the  proximal  side  of  the  clamps.  When  the  bleeding  from  the 
pedicle  has  been  stopped  the  packs  are  removed  and  the  subphrenic 
space  inspected  for  bleeding,  which  must  be  checked  by  suture  or 
ligature.  Then  the  abdominal  incision  is  closed  in  layers  in  the  usual 
manner.     After  splenectomy  for  abscess,  or  when  there  is  some  oozing 


Fig.   198. — Splenectomy — the    Pedicle    E.xposed    by    Rotating    the    Spleen   towards    the 
Patient's  Right.     Note  the  Tail  of  the  Pancreas. 

from  adhesions,  or  in  traumatic  cases,  it  may  be  advisable  to  leave 
some  gauze  drainage  in  the  wound.  It  can  be  brought  oiit  at  the 
lower  angle  of  the  incision  or  preferably  through  a  counter  incision  in 
the  loin. 

Splenotomy. — Cysts  and  abscesses  are  the  indications  for  spleno- 


8o4  TECHNIQUE    OF   OPERATIONS 

tomy  and  as  a  rule  it  is  undertaken  because  splenectomy  is  difficult 
or  impossible  owing  to  adhesions.  Under  such  circumstances  the 
general  peritoneal  cavity  usually  is  rather  well  walled  off  by  the  ad- 
hesions, but  in  any  case,  if  exposed,  it  should  be  carefully  protected 
with  gauze  before  the  spleen  is  cut  into.  The  abdominal  incision 
may  be  made  over  the  most  prominent  portion  of  the  tumor  or  through 
the  outer  third  of  the  left  rectus  muscle.  There  are  no  special  points 
in  technique. 

Abscesses  and  cysts  that  develop  backward  often  can  be  reached 
more  easily  by  a  transpleural  operation,  resecting  a  portion  of  the 
ninth  or  tenth  rib  in  the  postaxillary  line,  sewing  the  layers  of  the 
pleura  together  to  shut  off  the  lung  and  general  pleural  cavity  (p.  791), 
and  then  going  through  the  diaphragm  into  the  abdomen. 

The  spleen  may  also  be  reached  through  the  lumbar  incision  for 
kidney  operations,  if  this  is  extended  well  forward.  On  account  of 
mistaken  diagnosis  this  has  been  done  quite  frequently. 

Splenopexy. — Splenopexy  is  an  operation  that  is  very  seldom 
performed.  It  is  indicated  in  comparatively  few  cases,  such  as  those 
with  the  spleen  normal  in  size  but  freely  movable,  and  without  any 
pathological  change  in  its  substance  or  its  capsule.  These  cases 
occur  very  rarely. 

Moynihan  (1908)  mentions  various  methods:  i.  Suture  of  the 
spleen  to  the  diaphragm  or  abdominal  wall  (Tuffier).  This  is  very 
likely  to  cause  severe  hemorrhage.  2.  Fixing  the  spleen  in  place 
by  surrounding  it  with  gauze  to  e.xcite  the  formation  of  adhesions 
(Kouwer).  3.  Burying  the  spleen  beneath  a  pocket  of  peritoneum 
on  the  diaphragm  (Rydygier).  4.  Bringing  the  spleen  out  of  the 
abdomen  into  the  lumbar  fossa  and  fastening  it  there  to  make  it  a 
retroperitoneal  organ  (Bardenheuer).  5.  A  case  described  by  Basil 
Hall  in  which  the  lower  pole  of  the  spleen  was  fastened  between  the 
layers  of  the  abdominal  wound. 

Of  all  these  methods  practically  the  only  one  that  is  used  now 
is  that  of  packing  gauze  around  the  spleen  so  that  it  will  be  held  in 
its  normal  position  by  the  formation  of  adhesions. 

No  fatalities  are  reported  after  splenopexy  for  movable  spleen.  In 
most  cases  the  result  has  been  satisfactory,  but,  as  mentioned  at  page  732, 
splenectomy  was  required  later  in  a  patient  in  the  German  Hospital, 
owing  to  increase  in  size  of  the  spleen. 


INDEX  OF  NAMES 


Abbe,  503 

Aborg,  297 

Abrami,  615 

Adams,  229 

Adler,  221 

Alamartine,  264 

Albers,  215 

Albert!,  611 

Albu,  159,  536 

Alessandri,  522 

Alexander,  122,  192 

Alexander,  E.  G.,  664 

Alexinski,  264 

Allingham,  129 

Allivasato,  301 

Altschul,  264,  268,  269,  374 

Ambrose,  298 

Anders,  201 

Anderson,  215,  216,  302 

Andral,  218 

Andrews,  155 

Angler,  281 

Anschiitz,  582 

Apolant,  521 

Appel,  149 

Archibald,  105,  416,  617,  619,  638, 

672 
.\myand,  178 
Arnaud,  632,  646,  654 
Arnsperger,  620,  662 
Aschoff,  422,  449,  583 
Asellius,  611 
Ashby,  132 

Ashhurst,  John,  Jr.,  175,  217,  291 
Ashhurst,  W.  W.,  714,  791 
Assmy,  761 
Ast,  159 

Auvray,  295,  553,  582,  594 
Axhausen,  149,  326 

Bacmeister,  419,  420,  449,  583 

Baildon,  531 

Baillet,  150 

Baker,  124,  295 

Baldauf,  200 

Balfour,  116,  359,  390,  392,  739 


Balser,  612,  621,  631 

Bamberger,  105,  242 

Banti,  740,  752 

Barber,  363,  512 

Barchasch,  221 

Bard,  208,  694 

Bardachzi,  297 

Bardeleben,  183,  305,  345,  578 

Bardenheuer,  241,  804 

Barjon,  i8g 

Barlow,  403 

Barnard,  408 

Baron,  600 

Barr,  741 

Barrier,  562 

Bartels,  598,  660 

Bartlett,  W.,  424 

Barton,  214 

Baruch,  523 

Basch,  213 

Bashford,  691 

Bassler,  174 

Batavyai,  308 

Battersby,  629 

Baud,  614 
639.  653,       Baudouin,  323,  512 

Bayer,  233 

Bazy,  201,  204 

Beadles,  580,  584,  585 

Beardsley,  131 

Beaumont,  31,  397 

Becker,  689 

Beckman,  372 
,  305  Beckmann,  242 

Benczur,  689 

Bender,  631 

Benjamin,  203 

Bennett,  210,  212,  347 

Benoit,  288 

Berard,  208,  274 

Berg,  230,  541 

Berger,  513 

V.  Bergmann,  175,  208 

Bernard,  557 

Bernard,  Claude,  611,  623 

Bernays,  305 
805 


8o6 


IXDEX 


Bernouilli,  245 

Bevan,  763 

Beyea,  169,  347 

Bidwell,  loi,  105,  114 

Bier,  169,  an,  514 

Billroth,  113,  175,  349,  398,  701 

Bindseil,  264,  268 

Biondi,  117,  702 

Bircher,  117, 160, 168,206,  228.323.347,652 

Bird,  223 

Bishop,  418,  419,  421,  488 

Blake,  183 

Blake,  J.  Bapst,  557 

Blanc,  391 

Bland-Sutton,  263 

Blecher,  169 

Bloodgood,  202,  647 

Bloom,  Homer  C,  547 

Boas,  256,  260 

Bochlendorf,  214 

Bocker,  560 

Bode,  522,  524 

Boeckel,  268 

Bogojawlensky,  558 

Bohm,  631 

Bohn,  691 

Boinet,  561 

Boldt,  633 

Boldyreff,  58 

Boljarski,  593,  598,  601 

Bolton,  67,  195 

Bond,  415.417,  568 

Bonnet,  26 

Bonniot,  26 

Boothby,  29 

Borchardt,  231 

Borchgre\Tnk,  149 

Borel,  P.,  227 

V.  Bornsdorff,  232 

Borrmann,  253 

Borzesky,  189 

Bosdorf,  522 

Bottazzi,  720 

Bouchard,  403 

Bourcart,  230 

Bourne,  104 

Bovaird,  742 

Bovee,  228 

Box,  149 

Boyd,  573 

Boykin,  122 

Brandt,  518 

Brauer,  366 


Braun,  124,  i  26,  267,  332,  373,  381 

Brechot,  iii 

Bremser,  559 

Brennerman,  172 

Brentano,  649,  655 

Brewer,  117 

Brewitt,  639 

Brinton,  70,  98.  218.  251 

Brissaud.  575 

Broca,  172 

Brockbank,  479,  529 

Broders,  221,  222,  246 

Brodowski.  207 

Brown,  150 

Brown,  T.  R.,  537 

Bruchi,  212 

Brun,  H.,  367 

Brunner,  C,  108 

Brunner,  F.,  121,  123,  193,  194 

Brush,  297 

Bryan,  396,  757 

Bryant,  631 

Bubenhofer,  442 

Buchanan,  308,  452 

Buchbinder,  513 

Budd,  462 

Budinger,  184,  1S7 

Bullitt,  118 

Bunge,  559,  631,  648,  652 

Bunts,  137 

Burckhardt,  594 

Burghard,  741 

Busch,  637,  639 

Buschi.  204 

Bythell,  242 

Cacko\ic,  306,  401 

Cade,  391 

Caffee,  242 

Caird,  120,  127 

Calderara,  105 

Cammidge,  487,  612,  623,  628,  630,  678, 

692,  704 
Campbell,  2r3 
Cannon,  49 
Cantani,  536 
Caparelli,  629 
Carle,  104,  179 
Carman,  65,  390,  392 
Camot,  618,  629,  632,  637 
Carrion,  144 
Carson,  242 
Catani,  175 


INDEX 


807 


Cauchoix,  562,  568,  570 

Cautley,  131 

Cawley,  612,  623 

Cazin,  119 

Cecil,  670,  703 

Cernezzi,  207,  208 

Chace,  40 

Chaput,  209,  212,  308,  381 

Charbonnel,  687 

Chauffard,  675,  677,  695,  750 

Chauvin,  279 

Chavannaz,  398 

Chevassu,  223 

Chevrier,  221,  223,  330 

Cheyne,  S37,  S4o 

Chiari,  224,  298,  598,  629,  637,  641,  657 

Childe,  275 

Chittenden,  722 

Chlumskij,  381 

Chomel,  204 

Chopart,  612 

Christian,  180,  203 

Chutro,  189,  214,  217,  301 

Chvostek,  194,  633 

Cipriani,  687 

Clairmont,  452 

Clark,  536 

Clarke,  229 

Clayton,  623 

Clement,  185 

Cleemann,  132,  200 

Clegg,  545 

Cloquet,  215 

Codivilla,  190,  702 

Codman,  192 

Coe,  477 

Coenen,  652,  655 

Coffey,  loi,  114,  169,  198,  702,  799,  797 

Coffin,  543,  552 

Cohn,  207 

Cole,  65,  204 

Cole,  L.  G.,  62 

Collin,  192 

Collins,  762 

CoUinschonn,  234 

CoUinson,  122,  127,  451 

Collum,  200 

Combenale,  556 

Connell,  390 

Connelly,  704 

Conner,  143,  144 

Connors,  122 

Cordua,  131 


Cotte,  367,  506,  591,  796 

Courvoisier,  470,  513,  524,  584,  590, 609,  766 

Cranwell,  242,  568,  570  ; 

Crile,  43,  259 

Crossan,  308 

Crouse,  203 

Cruveilhier,  70,  178,  213 

Cumston,  576 

Cuneo,  14,  252,  663,  702 

Cunningham,  164 

CurUng,  192 

Curschman,  221 

Gushing,  574 

Gushing,  Hey  ward,  313 

Cutler,  378 

Cyr,  548 

Czerny,  267,  399,  511,  590,  763 

Dandy,  64 

Dastre,  382 

Davaine,  559 

Davis,  G.  G.,  452,  602 

Davis,  J.  D.  S.,  286 

Davis,  W.  E.  B.,  514 

Dawson,  274 

Dean,  H.  P.,  190 

Deaver,  H.  C.,  122,  136,  462,  664 

Deaver,  J.  B.,  127,  279,  555,  659 

Decastello,  752 

de  Font-Reaulx,  241 

de  Graaf,  611,  621 

Dehmel,  308 

Deitz,  238 

Delageniere,  557 

Delamare,  178 

Delangre,  233 

Delbet,  569 

Delore,  189,  264 

Demoulin,  114,  171 

Demarquay,  86 

Denechau,  106,  400 

Dennis,  243 

Dent,  131 

Desjardins,  6i8,  623,  637,  672,  677,  702,  781, 

796,  799 
Deucher,  628 
Deve,  563,  569 
Devic,  208 
Dick,  647 
Diehl,  690 
Dieulafe,  178 
Dieulafoy,  67,  70,  73,  96,  119,  552,  575,  638, 

672 


8o8 


INDEX 


Dixon,  427 

Doberauer,  632 

Dobson,  14,  253 

Dock,  558,  559 

Doening,  210 

DoUey,  536 

Domenici,  40 

Donati,  589 

Donhauser,  721 

Dorr,  418 

Douglas,  170,  479,  560 

Doujon,  298 

Dowd,  244,  689,  735 

Downes,  134,  182,  225.  574 

Doyen,  179,  183,  332,  381 

Dreesmann,  646 

Drummond,  558 

Dubar,  556 

Dubois,  305 

Dujarier,  214 

Dujon,  231 

Dunn,  190 

Dupraz,  216 

Dupre.  234 

Durante,  221 

Duret,  169,  347 

Diirk,  221 

Dutil,  691 

Duval,  623,  634,  639,  702,  78s 

Duvernoy,  215 

Eastes,  132 

Ebner,  620,  621,  631,  646,  652 

Ebstein,  209 

Ecklin,  697 

Edgecombe,  616 

Edler.  593,  594,  598 

Edmunds,  306,  399 

Egdahl,  616,  634,  639,  643 

Einhorn,  621,  626,  687 

V.   Eiselsberg,  loi,  105,  113.  181,  22c,  227, 

344,  373.  624 
Eisendrath,  406 
Eliot   406,  509 
Elliot,  643,  752,  760 
Elsberg,  406 
Else,  418 
Emerson,  200 
Enderlen,  loi,  277,  510 
Engel,  612 
Engelbert,  318 
Engelhardt,  575 
Engelhorn,  255 


Engel-Reimers,  215 

Engle,  621 

English,  308 

Eppinger,  435,  445,  554,  691,  752 

Erdmann,  175,  451,  584 

Erlach.  207 

Eshner,  443 

Estes,  468,  614 

Eusterman,  105,  204 

Ewald,  47 

Ewing,  249 

Exner,  420 

Fagge,  142 

Fantino,  104 

Farquhar,  149 

Farr,  122 

Fasano,  655 

Faulhaber,  277 

Faure,  536 

Fedeli,  628 

Feivez,  281 

Fenger,  472,  780 

Fenwick,  210.  213,  214,  215,  244,  249, 

280 
Ferguson,  691 
Feroualle,  130 
Fertig,  598 
Fetzer,  579 
Feurer,  264,  268 
Filippini,  582 
Fink,  401 
Fink,  F.,  442 
Finkelstein,  403 
Finnel,  215 
Finney,  loi,  105,  109,  no,  124,  148,  326 

614,  701,  703,  785 
Finsen,  564 

Finsterer,  593,  596,  598 
Fischer,  213,  235,  399,  454 
Fisk,  134 

Fitz,  612,  615,  636 
Fleckenstein,  522 
Fleig,  158 
Fleiner,  164 
Fleo,  627 

Flexner,  224,  548,  618 
Flint,  420 
Foote,  i8s,  578 
Foote,  E.  M.,  451 
Forgue,  279,  291,  295 
Fciwelin,  08g 
Fowler,  332,  380,  381,  561,  569 


INDEX 


809 


Fowler,  R.  S.,  118,  562 
Fox,  244 

Fraenckel,  297,  299 
Frangenheim,  324 
Frank,  201 
Frank,  J.  P.,  477 
Franke,  539,  660,  702 
Frattini,  175 
Frazier,  283,  720,  743 
Freeman,  403,  579,  582,  793 
V.  Frey,  240 
Freytag,  72 

Friedenwald,  no,  244,  247 
Friedman,  94 
Funke,  481 
Futterer,  584 

Gage,  307 

Galen,  6ri 

Gallavardin,  208 

Galliard,  623 

Gallic,  138,  140 

Galippe,  622 

Gallois,  215,  216,  302 

Galpern,  loi,  105,  127,  264 

Gandy,  67,  192,  221 

Gar,  264 

Garbat,  433 

Gardiner,  178 

Garre,  400,  469,  523 

Gaston,  J.  Mc  F.,  515 

Gaultier,  636 

Gay,  443 

Gayet,  219 

Geill,  299 

Geinitz,  loi,  115 

Genrich,  192 

Gerard,  420 

Gerard-Marchant,  539 

Gerster,  John,  759 

Gersuny,  179,  451,  515 

Ghedini,  567 

Gibbon,  129,  453 

Gibson,  122,  129 

Giffin,  239,  242,  735,  736,  754 

Gilbert,  40,  617 

Gill,  298 

Gilly,  217 

Ginsburg,  510 

Giordano,  594 

Giovanni,  697 

Giuliani,  208 

Glaessner,  687 


Glaser,  237 

Glaubitt,  221 

Glenard,  43,  165,  537 

Glinski,  613 

Gluck,  323 

Glucksman,  190 

Glutzinsky,  259 

Goodall,  693 

Goodhart,  132 

Gordinier,  574 

Gordon,  396 

Gosset,  390,  401,  762 

Gossmann,  221 

Gould,  190 

GouUioud,  207 

Gourrand,  212 

Graham,  218,  536 

Graham,  C,  93,  105 

Gramse,  324 

Graser,  598 

Gray,  105,  138 

Greene,  242 

Greenough,  559 

Gregg,  433 

Gregoire,  202 

Grenier  de  Cardenal,  237 

Griffith,  442,  579 

Gross,  121,  401,  403,  65s,  738 

Grossenbacher,  721 

Grossman,  218 

Grunert,  522 

Guerry,  511 

Guibal,  287 

Guibert,  614 

Guidiceandrea,  621,  629 

Guillemot,  179 

Guinard,  656,  655 

Guisez,  217 

Gulecke,  631 

Gumprecht,  164 

Gussander,  233 

Gussenbauer,  612 

Guthrie,  241 

Gutteridge,  528 

Haasler,  502,  514 

Haberda,  297 

V.  Haberer,  230,  452 

Habheggar,  132 

Habs,  522 

V.  Hacker,  179,  185,  331 

Hadra,  381 

Hagen,  300,  595,  598 


8io 


INDEX 


Haggard,  138,  283 

Hahn,  192,  215,  287,  400,  647,  652 

Hake,  206 

Hall,  Basil,  804 

Haller,  477,  6u 

Hallon,  144 

Halsted,  514,  591,  647 

Hamann,  390 

Hamilton,  Edw.,  559 

Hammer,  169 

Hammond,  433 

Hanau-.\Ibrecht,  143 

Hanot.  554 

Hansemann,  207,  632 

Hansen,  149 

Harley,  552 

Harris,  242,  536,  616,  741 

Harte,  90,  306,  397,  599 

Hartmann,  103,  iii,  118,  191,  214.  274,334, 

351,  363,  370,  397 
Hartwell,  736 
Hattute,  221 
Haudek,  65,  274 
Hausmann,  226 
Hayem,  209,  248,  750 
Hebb,  21  s 
Hedlund,  187,  230 
Hein,  420 
Heineke,  721 
Heinz,  212 
Heister,  536 
Heller,  522 
Helly,  621,  630 
Helm,  614 
Hemmeter,  98 
Henle,  178 
Henschel,  132,  399 
Henzelman,  595 
Herczel,  307 
Hermes,  230 
Herrick,  543,  552 
Hertz,  77,  229,  534 
Herzen,  324,  722 
Herzog,  596,  741 
Hess,  127,  442,  599 
Hesse,  283 
Heubner,  133 
Heurnius,  6n 
Heusner,  513 
Hewlett,  630 
Heyrovsky,  420 
Hildebrand,  300 
Hilgenreiner,  119,  179,  188,  192,  254,  307 


Hill,  743 

Hillier,  693 

Hilton,  3 

Hinds,  212 

Hinton,  401 

Hinz,  326 

Hirschberg,  514 

Hirschfeld,  616 

Hirschmann,  326 

Hirschsprung,  131 

Hitzrot,  401 

Hobson,  200 

Hochenegg,  582 

Hodge,  i6g,  296 

HoEEman,  117,  149,  244,  261,  298 

Hoffman,  Friedr.,  477 

Holmes,  441 

Holscher,  541 

Holstein,  215 

Holzmann,  629 

Homans,  423 

Home,  178 

Hon  tang,  215,  216 

Hoover,  408 

Hoppe-Seyler,  415,  477,  482 

Horrocks,  188 

Hort,  67 

Horton-Smith,  541 

Hosch,  281 

Hotchkiss,  457 

Houdard,  279 

Houghton,  596 

Houlong,  302 

Hubbard,  595,  598,  722 

Hulst,  692 

Humbert,  287 

Hunt,  378 

Hunter,  438 

Huntington,  734 

Hutchinson,  215 

Ipsen,  298 
Iselin,  287 
Israel,  553 

Jacobi,  263 
Jacobs,  582 
Jacobson,  306 
Jaboulay,  216,  332,  381 
Jackson,  Chevalier,  305 
Jaffe,  583 
Jamieson,  14,  253 
V.  Jaksch,  748 


INDEX 


8ii 


Janowski,  584 

Jeanbrau,  291,  295 

Jeannel,  307 

Jedlicka,  iii,  114,  133,  183,  364 

Jefferson,  46 

Jefferson,  G.,  192,  279 

Jensen,  227 

Jessop,  r49 

Jianu,  233,  324 

Johansson,  452 

Johnston,  685,  739 

Jones,  189,  468 

Jones,  Sidney,  190 

Jonnesco,  218,  344 

Jourdan,  785 

Judd,  248,  765 

Jundell,  433 

Junghans,  259 

Jiirgensen,  283,  628 

Jurist,  641 

Justi,  sio 

Kader,  320 

Kahlden,  578 

Kakels,  703 

Kammerer,  183,  346 

Kanavel,  752 

Karewski,  369 

Karsner,  216 

Katzenstein,  273 

Kauffmann,  399 

Kaupe,  119 

Kausch,  104,  26s,  389,  S91 

Kayser,  228 

Keen,  575,  582 

Kehr,  150,  401,  423,  433,  450,  461,  481,495. 

509,  522,  560,  565,  608,  621,  634,  639,6  62, 

674,  769 
Keith,  200 
KeUing,  47,   117,  143,   259,  377,  381,  382, 

400 
Kelly,  535 

Kelly,  A.  O.  J.,  253,  41S-  422,  449.  553.  589 
Kemke,  207 
Kerr,  234 
Key,  392 
Khosroyeff,  212 
Kieffer,  S43 
Kilgore,  201 
Kilgour,  607 
Kinnicutt,  160,  685 
Kirchheim,  576 
Kirk,  122,  130 


Kirmisson,  171 

Kirschner,  326,  758 

Klebs,  25s,  706 

Klein,  179 

Klob,  614 

Klemperer,  752 

Knaggs,  287 

Knott,  578 

Koch,  Joseph,  418 

Kocher,  loi,  103,  105,  183,  230,  246,  262, 

267,  276,  324,  351,  502,  514,  761,  763, 

782,  785,  793 
Kolaczek,  i88,  206 
Konig,  287 

Konjetzni,  248,  583,  584 
Korte,   130,   179,   237,  301,   512,  524,  591, 

632,  639,  647,  649,  657,  676,  685,  710, 

791 
Koslowsky,  559 
Kouwer,  S04 
Krabbel,  loi,  115 
Kramer,  419,  421 
Kraske,  401 
Krause,  236,  276 
Krecke,  377 
Kriege,  120 
Krogius,  III 
Kroiss,  127  ,658 
Kronlein,  267 
Krukenberg,  183,  345 
Krumbhaar,  720,  743,  748,  750,  753 
Krymholz,  234 
Kiibig,  444,  454 
Kuhn,  503,  691 
Kulenkampff,  612 
Kuliga,  201 

Kiimmel,  loi,  114,  127,  502,  513,  685 
Kundrat,  96 
Kuntzmann,  627 
Kussmaul,  141,  158 
Kiister,  780 
Kiittner,  roi,  248,  737 

Labhardt,  399,  400 
Lacher,  238,  614 
La  Couture,  687 
Ladeveze,  204 
Laennec,  563 
Laffer,  143,  148 
Lambert,  176  ■ 
Lambotte,  322,  324 
Lammero,  217 
Lancereaux,  612,  616,  623 


8l2 


INDEX 


Landau,  537,  568 

Landerer,  igo 

Lane,  69 

Lange,  212 

Langenbuch,  179,   470,  484,  502,  512,  546 

574,  578,  579 
Langerhans,  179,  230 
Lanphear,  149 
Lanz,  150 
Lapointe,  582 
Lardennois,  364 
Lartigau,  417 
Laspeyres,  194 
Latarjet,  26 

Lauenstein,  332,  381,  780 
Lautschner.  298 
Lavenson,  441,  472,  473,  624 
Lazarus,  621,  685,  707 
Leary,  427 
LeBec,  531 
Lebert,  98 
LeBlanc,  492 
Lecene,  120,  647 
Lecreuz,  556 

Ledderhose,  174,  210,  212 
LeDentu,  305 
Lediard,  462 
LeFillier,  305 
Leflaive,  215,  216,  302 
Legg,  536 
Leisrink,  287 
Leith,  227,  229 
Leraoine,  616 
Lengemann,  253 
Lenhartz,  99 

Lennander,  77,  229,  377,  390 
Lenormant,  240,  285,  647 
Leonard!,  527 
Leotta,  391 
Lerat,  613 
Leriche,  203,  222,  259,  275,  331,  361,  506, 

632,  646,  654,  692,  697,  785 
Lesshaft,  132 
LetuUe,  204,  612,  692 
V.  Leube,  99 
Leue,  536 
Levy,  756 
LeWald,  182,  225 
Lewerenz,  607 
Lewis,  Morris,  747 
Lewisohn,  117 
Lexer,  324 
Lichtenstein,  149 


Lichtheira,  686 
Licini,  583,  589 
Lieblein,  119,  179,  188, 

397 
Lieutaud,  620 
Lilienthal,  401 
Linder,  647 
Link,  687,  797 
Linke,  149,  150 
Lippmann,  415,  617 
Litler-Jones,  242 
Littig,  149 
Little,  189 
Littlewood,  381 
Lobker,  131 
Lockwood,  247 
Loewy,  601 
Loison,  542 
Loreta,  175 
Lotheissen,  577 
Lotsch,  758 
Louis,  221 
Lowenburg,  136 
Lowi,  624 
Lucas,  308 
Lucke,  332,  582,  612 
Ludolph,  629 
Lyle,  627 
Lyman,  212 
Lyng,  288 
Lyon,  459,  732 

MacCallum,  158 
MacCarty,  246,  466 
MacKenzie,  567 
MacMonagle,  150 
MacNeal,  40 
McBurney,  503,  782 
McConnell,  472 
McCosh,  90,  210 
McDill,  550,  793 
McDowell,  246 
McGuire,  242,  287 
McKendrick,  159,  164 
McLaren,  208 
McWilliams,  543,  559 
Macaigne,  615 
Macevitt,  149 
Macewen,  J.  A.  C,  406 
Mackenzie,  3,  201 
Madelung,  560 
Magnus-Alsbeben,  208 
Mall,  48 


192,  254,  390,  392. 


INDEX 


813 


Manson,  551,  552 

Marchand,  736 

Marckwald,  574 

Marshall,  5gg 

Martin,  287,  391 

Martin,  E.,  175 

Martin.  F.,  533 

Martin,  Walton,  293 

Martina,  631,  633 

Marton,  631,  641 

Mason,  427 

Massmann,  276 

Matas,  304 

Mathieu,  508,  515.  541 

Mathieu,  Paul,  441 

Matthews,  139 

Mauclaire,  296,  400,  601,  702 

Maugeret,  620,  667 

Mauler,  209 

Maurizot,  367,  591,  796 

Maury,  Draper,  516 

May,  105 

Maydl,  in,  369,  403 

Mayer,  215,  454,  594 

Maylard,  132,  283 

Mayo,  31,  105,  106,  129,  186,  189.  igo,  204, 

219,  245,  267,  268,  269,  273,278,333,336. 

359,  364,  390.392.439.478,497,514.554. 

557,  574.  584.  634,  637,  667,  7SO 
Mayor,  O.,  614 
Mazotti,  230 
Meckel,  420 

Meer\vein,.3oo,  307,  308 
Melchior.  202.  541 
Meltzer,  136 
Mendel,  722 
Menetrier.  249 
Menne,  302 
Mercade,  598 
Meredith,  766 
V.  Mering,  612,  623 
Mesnard,  130 
Mettin,  657 
Meunier,  19s 
Meyer,  423,  721 
Meyer,  Willy,  176,  325,  367 
Michel,  40s,  655,  672,  674,  738 
Mignot,  423,  425,  479 
Mikaye,  264 
Mikulicz,  109,  175,  185,  229,  261,  267,300, 

357.  377.  406.  522 
Millard,  485 
Miller,  122,  522 


Minkowski,  612,  623,  750 

Mintz,  104 

Miodowski,  207 

Mirallie,  692,  697 

Mitchell,  A.  B.,  loi 

Mixter,  138 

Mollard,  207 

Monprofit,  185,  512,  559 

Monro,  208 

Monsarrat,  10 1,  488 

Montgomery,  429 

Moore,  304 

Moore,  E.  C,  204 

Moorhead,  149 

Morgagni,  178,  204,  206,  477 

Morgan,  224.  225 

Morison.  no,  558 

Morris,  283,  560,  721 

Morris,  Henry,  562 

Morris,  R.  T.,  659 

Moschcowitz,  396,  763 

Mosetig-Moorhof,  i8g 

Mosse,  391 

Moullin,  154 

Moynihan,  4,  68,  85,  89,  gS,  loi,  115,  119, 
127,  178,  180,  181,  183,  100, 195,  212,  227, 
26s,  269,  272,  333,  336,  381,390.397,465, 
472,  488,  540,  67s,  695,  702,  804 

Mugnai,  750 

Muhsam,  454 

Miiller,  120,  418,  531 

Miiller,  P.,  144 

Mumford,  245,  251 

Munro,  119,  542 

Murard,  759 

Muroya,  620 

Murray,  213 

Musgrave,  545 

Muspratt,  651 

Musser,  583,  614,  635.  640 

Myer,  2 1 2 

N.4UMANN,  241 
Naunyn,  419,  421 
Neck,  143 
Neelsen,  207 
Neilson,  T.  R.,  406 
Neugebauer,  737 
Neumann,  233,  300 
Neurath,  131 
Newman,  298 
Nichols,  208,  427 
Nicoladoni,  183,  331 


8i4 


INDEX 


Niemack,  443 

Niemeyer,  207 

Ximier,  651 

Niosi,  233 

Nisbet,  98,  163,  222 

Noetzel,  389 

Noguchi,  630,  689,  720 

V.  Noorden,  625 

Nordmann,  619 

Norman,  211 

Norris,  736 

Notzel,  599,  639,  651,  652 

Novak,  228 

Nussbaum,  305 

OcHSNER,  28,  47,  774 

Oddi,  416,  515 

Oehler,  512 

Okinczyc,  364 

Olivier,  692 

Oltmann,  234 

Opie,  i6o,  612,  616,  618,  621,  623,  630,  639, 

662,  668 
Oppenheimer,  194,  509,  591 
Orth,  96,  213,  233,  297 
Oser,  691 

Osier,  131,  736,  740 
Otis,  594 
Otto,  425 
Outerbridge,  591 

Packard,  424 

Page,  227 

Paget,  607 

Pallares,  214 

Pallas,  559 

Pantzer,  114 

Paracelsus,  420 

Parkes,  502 

Parrot,  208 

Pascale,  557 

Patel,  219,  398 

Paterson,  57,  106,  129,  184,  185,  248,  381, 

390.  392 
Pauchet,  364,'39i,  393 
Paus,  260 
Pawlow,  529,  722 
Payr,  478,  631 
Pean,  349,  539 
Pearce,  720,  743 
Peck,  115,  120,  127 
Pellman,  573 
Pemberton,  624 


Pendl,  234 

Pepper,  686 

Perkins,  739 

Perls,  207,  579 

Permann,  241 

Perr\',  190,  193,  204,  308 

Perthes,  763 

Petersen,  333,  337,  509 

Petit,  149,  23s 

Petit,  J.  L.,  503 

Petren,  120 

Petry,  297 

Pfaundler,  133 

PfeiEfer,  659 

Phillips,  S.,  615 

Pic,  694 

Pilcher,  364 

Piorkovvsky,  541 

Pinatelle,  124 

Piquand,  403 

Pirie,  105 

Plummer,  173 

Poirier,  207 

Polya,  117 

Poncet,  222,  697 

Ponfick,  759 

Ponomarew,  212 

Porter,  219,  531 

Porter,  C.  B.,  651 

Posadas,  569 

Postempski,  241 

Power,  D'Arcy,  747 

Preble,  95 

Price.  429 

Pringle,  600,  793 

Priischer,  584 

Prudden,  561 

Purser,  444 

Putnam,  172 

QuAiN,  203,  212 

Qu^nu,  119,  390,  429,  541,  569,  592,  623, 

634,  639 
Quincke,  435 

Rahn,  614 
Railton,  704 
Rammstedt,  137 
Ramsay,  306 
Randisi,  213 
Ransohoff,  140 
Ranzi,  554 
Rasmussen,  179 


INDEX 


815 


Ravdin,  279 

Ravenna,  703 

Read,  215 

V.  Recklinghausen,  573,  612,  617 

Rehfuss,  626 

Rehn,  298,  462 

Reichel,  399 

Reid,  429 

Reidel,  277 

Reiman,  71,  247,  460 

Remedi,  617 

Remijnsee,  274 

Rendl,  233 

Rendu,  215,  216,  302 

R^non,  223 

Reuss,  158 

Revenstorf,  305 

Revilliod,  298 

Rewitz,  277 

Rhein,  235 

Rheinstein,  489 

Rhoads,  543 

Ricard,  221,  223,  330 

Richardson,  560,  704,  714 

Richardson,  M.  H.,  26,  497 

Richet,  615 

Richter,  137,  424,  513,  631,  641 

Ricketts,  SS6 

Riedel,  454,  462,  481,  522,  534,  612, 635,  780 

Riegner,  243 

Riesman,  727 

Riggs,  509 

Rintel,  401 

Rivet,  677 

Robert,  286 

Roberts,  204,  531 

Roberts,  J.  B.,  575 

Robertson,  138,  140 

Robineau,  171 

Robinson,  148 

Robinson,  Byron,  539 

Robson,  4,  85,  89,  98,  113,  119,  132,  180, 
194,  212,  227,  265,  267,  272,  33i,  378, 
390,  40s,  446,  470,  474,  487,  525,  529, 
582,  612,  624,  626,  628,  630,  657,  658, 
667,  672,  692,  704,  765,  768,  782 

Rockwitz,  331 

Roddick,  614 

Rodelius,  122 

Rodman,  in,  120 

Rodocanache,  301 

Roger,  628 

Rokitansky,  612,  641 


Rolleston,  26,  133,  281,  425,  441,  479,  553. 

575,  588,  740 
Romanelli,  628 
V.  Roojen,  390 
Ropke,  245 
Rose,  E.,  614 
Rosenheim,  174 
Rosenow,  68,  418 
Roser,  567 

Ross,  122,  276,  407,  451,  601,  732 
Rother,  478 
Rotter,  655 
Rouhier,  391 
Rouis,  546,  548 
Roussel,  147 
Routier,  143 

Roux,  173,  322,  332,  583,  792 
Rovsing,  169 
Rowlands,  229 
Roy,  722 
Ruggi,  702 
Runge,    614 
Russdorf,  213 
Russell,  174 
Russell,  Hamilton,  568 
Ruth,  143,  148 
Ruyschius,  214 
Ryan,  568 
Rydygier,  111,349,  804 

Saake,  230 

Sahli,  628 

Sailer,  235,  616,  672 

Saint-Girons,  615 

Salomon,  628 

Salomoni,  237,  241,  285,  564 

Santy,  264 

Sappey,  32,  614 

Sauerbruch,  366 

Sauve,  275,  367,  591,  701,  796 

Savariaud,  119 

Sawyer,  574 

Schachner,  444 

Schede,  401 

Schiassi,  283,  750 

Schievelbein,  452 

Schiff,  722 

Schirmer,  618 

Schlesinger,  159 

Schloffer,  183 

Schlossmann,  473 

Schmackpeffer,  615 

Schmidt,  627 


8i6 


INDEX 


Schmidt,  Meinhard,  131 

Schmitt,  300 

Schmorl,  599 

Schnarrwyler,  227 

Schnitzler.  179.  59Q 

Schomerus,  179,  183 

Schrader,  582,  583 

Schroeder,  478 

Schiller,  230,  234 

Schiiller,  588,  590 

Schupmann,  622 

Schiippel,  472,  575 

Schwabe,  Daniel,  305 

Schwarz,  391 

Schwyzer,  131 

Scrimger,  105 

Scudder,  129,  137,  242.  33^ 

Scully,  87,  120,  194 

Sedillot,  318 

Seelig,  144 

Segre,  450,  692,  703 

Seidel,  529 

Seigel,  288 

Selten,  759 

Sencert,  20,  318,  366 

Sendler,  514,  702 

Senn,  705 

Senn,  Nicholas,  612 

Serege,  43 

Serey,  462 

Severino,  740 

Shapiro,  736 

Sharp,  Gordon,  615 

Shattuck,  704 

Shaw,  190,  193,  200,  204, 

Sheldon,  220,  759 

Sherren,  loi.  105,  11 

444 
Sherrill,  283 
Sherwood,  307 
Short,  loi,  105,  120 
Shuyveninoff,  207 
Siegert,  584 
Sigaud,  203 
Silbermark,  189 
Silvestri,  42 
Simmonds,  221 
Simmons,  433.  574 
Simon,  274,  628,  691 
Simonds,  742 
Simonin,  615 
Singley,  301 
Sinjuschin,  233,  234 


308 


iiS,  122,  198,  212, 


Sippy,  100,  117 
Sklifossowsky,  209 
Slajner,  591 
Sloan,  216 
Sloane,  215,  302 
Smithies,  224,  245,  247, 
Socin.  332 
Solieri,  454 
Sommarin,  150 
Sorrentino,  284 
Soupault.  104 
Spassokukozki,  400 
Speese,  510,  511,  616 
Spencer,  274 
Spiess,  611,  621 
Ssaweljew.  53b 
Stamm,  320 
Stauder,  283 
Stavely,  203 
Steaton,  401 
Steel,  171 
Stefani,  703 
Stein,  236 
Steiner,  206,  208 
Stengel,  743 
Stern,  131 
Steudel,  104,  381 
Stevens,  210 
Stewart,  64.  200 
Stewart,  G.  D.,  363 
Stieda,  651,  704 
Stierlin,  150 
Stiles,  351 
Still,  134,  478 
Stillman,  748 
Stimmel,  433 
Stockis,  217 
Stone,  245,  442 
Stoner,  213 
Strassman,  245,  297 
Strauss,  117,  134,  138 
Struthers,  122,  127 
Stubenrauch,  509 
Sullivan,  122,  127,  516 
Summers,  306 
Surmay,  369 
V.  Sury,  218 
Suter,  284,  287 
Sutherland.  741 
Sweet,  624 
Sweet,  J.  E.,  795 
Syme,  280 
Symmers.  736 


254 


INDEX 


817 


Tait,  451 

Tarnier,  171 

Tavel,  322, 

Tawastsjerna,  300 

Taylor,  VV.  J.  gs 

Tfmoin,  iii,  264,  268,  273 

Templeton,  149 

Terrier,   114,   148,  331,  380,  382,  451,  470, 

502,   514,   535,   553,   582,   594,  636,  675, 

761,  763,  779,  785 
Terry,  201 
Thevenard,  401 
Th6venet,  633,  756 
Thiersch,  612 
Thiroloix,  706,  620 
Thole,  595,  607 
Thomas,  429 
Thommen,  300 
Thompson,  242,  562 
Thomson,  218 
Thomson,  John,  133,  478 
Thorbeck,  210 
Thorpe,  129 
Thornton,  513,  556 

Thornton,  Knowsley,  503,  553,  568,  791 
Tilanus,  305 
Tilger,  206,  213 
Tilton,  593 
Tinker,  521 
Tixier,  615 
Tomaschny,  643 
Torday,  192 
Torrance,  150.  742 
Trafeyer,  629.  641,  657 
Trantenroth,  131 
Travers,  190 
Treves,  442,  462 
Tricomi,  702 
Troisier,  615 
Truhart,  617,  632,  637 
Trump,  200 
Pschepurowski,  631 

Tviffier,  114,  119,  214,  288,  522,  542,  702,  804 
Tiirmoos,  233 
Turner,  105,  no,  149,  632 
Turnure,  215 
Tyson,  263 

Uluann,  512 
Ungar,  297 
Unruh,  400 
Upcott,  591 
Upham,  236 
52 


Vallas,  216 

Van  Valzah,  98,  163,  222 

Vassalo,  361 

Vatter,  302 

Vautrin,  502,  672,  681,  785 

V6gas,  568 

Venturelli,  281 

Verliac,  223 

Verrey,  522 

Verse,  210 

Veyrasset,  185 

Vidal,  555,  613 

Vierhuffs,  541 

Vierordt,  561 

Villandre,  522 

Villar,  622,  657 

Villard.  124,  633,  703,  759 

Villareal,  702 

Villemin,  171 

Violett,  468 

Virchow,  213,  207,  706 

Volkmann,  403 

Volleker.  516 

Voswinckel,  300 

Wachenheim,  131 

Wade,  209 

Wagner,  122,  40 1 

Walker,  120,  287 

Wallace,  149,  293,  602,  756 

Wallis,  114 

Walls,  136 

Walton,  511 

Warbasse,  305 

Waring,  546,  596 

Warthin,  6i6,  623,  740,  743 

Waugh,  6g,  203,  422 

Webb,  105 

Weber,  131,  200 

Webster,  217 

Wechselmann,  211 

Wegele,  212 

Weil,  264,  375 

Wefir,  Robt  F.,  190,  193 

Weiss,  473 

Weisser,  560 

Weissker,  521 

Welch,  244 

Wendel,  175,  216,  366 

Werner,  233 

Wernstedt,  134 

West,  742 

Wetterstand,  120 


INDEX 


White,  Hale,  255,  553,  579,  691,  703 

Whiting,  371 

Wickhoff,  51  s 

Widal,  750 

Widemann,  237 

W'ideroe,  259 

Wiener,  367 

Wier,  1 8s 

Wiesinger,  231,  233 

Wilensky,  396 

Wilke,  234,  298 

WiUe,  630 

Williams,  637,  639 

Wilms,  117,  595,  598 

Wilson,  246 

V.  Winiwarber,  515 

Winckler,  759 

Winslow,  305 

Winsor,  Henry,  531 

Winton,  584 

Wirsung,  611 

Wirth,  160 

Witzel,  319 

Wohlgemuth,  630,  65S,  689 

Wolflf,  259,  303,  452 


Wolfler,  178,  1S4,  331,  345,  381 

Wood,  124,  236 

Wood,  John,  241 

Wooley,  140 

Woolsey,  392 

Worden,  167 

Wright,  150,  390,  393 

Wrzosek,  41 8 

Wullstein,  323 

Wunscheim,  297 

Wynhausen,  212 


Yates,  281 
Yeomans,  582 
Young,  125 

Zade,  143 
Zahn, 188 

Zeigler,  214,  216,  302 
Zeit,  171 
Zeller,  187 
Zenker,  584,  599 
Zesas,  223,  283 
Zweig,  400 


GENERAL  INDEX 


Abdomen,  preparation  for  operation,  309 
Abdominal  wall,  i 
Absorption,  intestinal,  39 
Abscess,  liver,  540 
amebic,  540 
classification,  543 
pathology,  544 
pyemic,  540 
symptoms,  547 
transpleural  hepatotomy,  791 
traumatic,  540 
treatment,  552 
tropical,  540 
pancreas,  654 
pericholecystic,  467 
spleen,  736 
subphrenic,  402 
diagnosis,  407 
treatment,  409 
Acne  pancreatica,  706 
"Acute  round  ulcer,"  73 
Adenase,  722 
Adenoma,  liver,  574 
pancreas,  703 
stomach,  209 
Adhesions,  perigastric,  155 
Alimentary  tract,  movements,  44 
Ampulla  of  Vater,  22 
Amylase,  34 
Amyloid  spleen,  748 
Amylopsin,  37 
Anamnesis,  53 
Anatomy,  i 
surface,  4 
topographical,  12 
Anemia,  pernicious,  752 

splenic,  739 
Aneurysm  splenic  artery,  splenectomy,  759 

hepatic  artery,  522 
Angeioma  liver,  574 

stomach,  217 
"Ante-thoracic       esophago-jejunostomy, " 

323 
Antilytic  serum,  99 
Apoplexy,  pancreatic,  638 
Appetite,  51 


"Appetite-Juice,"  35 
Artery,  coronary,  13 

cystic,  23 

gastric,  13 

gastro-epiploica  dextra.  13 

gastro-epiploic,  rupture,  302 

gastro-epiploica  sinistra,  13 

hepatic,  22 
aneurysm,  522 

mammary,  internal,  2 

pyloric,  13 
Atresia,  common  duct,  441 

pylorus,  132 
Auscultation,  56 
Azotorrhea,  627 

Bacteriology  of  biliary  passages,  415 
Banti's  disease,  739 
diagnosis,  745 
treatment,  749 
Bayonet  incision,  761 
Sevan's  incision,  763 
Beyea's  gastropexy,  347 
Bile  secretion,  37 
Bile-duct,  common,  atresia,  441 
carcinoma,  588 
injuries,  607 

obliteration,  congenital,  44t 
obstruction,  aneurysm,  522 
external,  521 
fibro-adenoma,  521 
movable  kidney,  521 
operation,  760 
rupture,  traumatic,  607 
stricture,  507 
congenital,  441 
Biliary,  colic,  483 

treatment,  500 
fistula,  524 
complete,  527 
external,  527 
incomplete,  527 
internal,  525 
mucous,  527 
pathological.  327 
postoperative  529 


819 


820 


INDEX 


Biliary,  fistula,  statistics,  524 
passages,  bacteriology,  415 

obstruction,  506 
peritonitis,  452 
tract,  surgical  diseases,  415 
typhoid  injection,  427 
sequels,  431 
Billroth's  gastrectomy,  353 

pylorectomy,  349 
"Board-like"  rigidity,  86 
Boas's  area,.  489 

test  meal,  57 
Brunner's  glands,  32 

Calcvlvs,    biliary   vide  cholelithiasis;  also 
gall-stone 
biliary,  4f  o 

common  duct,  469 
formation,  419 
hepatic  duct,  476 
pancreatic,  621,  685 
Cammidge  reaction,  678 
Cammidge's  test,  636 
Canalis  gastricus,  46 
Caput  medusas,  24 
Carbohydrate  digestion,  628 
Carcinoma  bile-ducts,  588 
duodenum,  279 
gall-bladder,  583 
treatment,  588 
liver,  579 
pancreas,  diagnosis,  699 

treatment,  701 
stomach,  244 

clinical  pathology,  249 
diagnosis,  260 
duodenostomy,  278 
extension  by  contiguity,  254 
gastrectomy,  275 
gastrostomy,  278 
Glutzinsky's  test.  259 
hemolytic  blood  test,  259 
jejunostomy,  278 
metastasis,  251 
pain,  257 
perforation,  255 
prognosis,  263 
resection,  277 
Salomon's  test,  259 
secondary,  255 
symptoms,  256 
treatment,  275 
vomiting,  257 


Cardioplasty,  175 

Cardiospasm,  173 

"  Catarrhal  jaundice,"  445 

Cavernous  angeioma.  spleen,  735 

Cephalic  duodeno-pancreatectomy,  702 

Charcot's  intermittent  fever,  494 

Cholangeitis,  445 

chronic,  446 

suppurative,  447 
Cholecystectomy,  773 

statistics,  504 

Terrier's,  775 
Cholecystendysis,  766 
Cholecystenterostomy,  315.  787 
Cholecystitis,  449 

calculous,  acute,  treatment,  503 

catarrhal,  acute,  450 

chronic,  459 

diagnosis,  457 

gangrenous,  453 

non-calculous,  454 

phlegmonous,  453 

suppurative,  451 

symptoms,  454 

treatment,  458 
Cholecysto-colostomy,  787 
Cholecysto-duodenostomy,  787 

statistics,  505 
Cholecysto-gastrostomy,  787 
Cholecysto-jejunostomy,  787 
Cholecystostomy,  767 

statistics.  504 

with  prolonged  drainage,  772 
Cholecystotomy,  767 

without  drainage,  766 
Choledocho-enterostomy,  510 
Choledochoplasty,  509 
Choledochostomy,  for  stricture,  513 

statistics,  505 
Choledochotomy,  502,  777 

retroduodenal,  784 

transduodenal,  502,  782 
Choledochus,  vide  common  duct 

drainage,  513 

resection,  509 
Cholelithiasis,  460 

diagnosis,  481 
e.xciting  causes,  480 
fever,  491 

operative  mortality.  497 
pain,  482 

referred,  485 
pathology,  461 


INDIX 


821 


Cholelithiasis,  predisposing  causes,  476 
"steeple"  chart,  491 
symptoms,  481 
tenderness,  487 
treatment,  495 
tumor,  491 
Cholesterin  gall-bladder,  465 
Chondroma,  spleen,  735 
Chvostek's  sign,  159 
Chyle,  40 
Chyme,  35 

Circulus  vitiosus,  380 
Cirrhosis,  liver,  553 
biliary,  554 
operations,  556 
portal,  553 
stomach,  218 
"Clay-colored  Stools,"  437 
Colic,  biliary,  483 

treatment,  500 
CoUins's  incision,  762 
Common  duct,  20 

calculus  in,  469 

treatment,  501' 
cyst,  472 
diverticulum,  472 
gall-stones,  494 
resection,  509 
stricture,  507 
Concretions,  stomach,  217 
"Congenital  acholuric  icterus,"  750 
Coronary  artery,  13 

ligament,  17 
"Corset-furrow,"  534 
"Corset-liver,"  534 
Courvoisier's  incision,  761 

law,  473 
Cranwell's  operation,  243 
Cushing's  suture,  313 
Cutaneous  hyperesthesia,  3 
Cyst,  common  duct,  472 
hydatid,  gaseous,  563 
liver,  559 
hydatid,  559 

complications,  570 
marsupialization,  568 
treatment,  567 
non-parasitic,  573 
pancreas,  704 
diagnosis,  712 
hydatid,  708 

Korte's  classification,  710 
proliferation,  707 


Cyst,  pancreas,  retention,  705 
traumatic,  707 
treatment,  714 
spleen,  732 
stomach,  213 
Cystadenoma,  liver,  575 
Cystic  artery,  23 
duct,  20 

calculus,  493 
treatment,  501 
gall-stones,  493 
obstruction,  469 
stricture,  507 
Czerny's  incision,  763 


Deglutition,  45 
Depage's  operation,  791 
Dermoid  cyst,  stomach,  214 
Desjardins's  pancreatic  point,  677 
Diabetes,  pancreatic,  623 
Diagnosis,  S3 

auscultation,  56 

inspection,  54 

mensuration,  56 

palpation,  54 

percussion,  55 

X-ray,  61 
Diaphragm,  central  tendon,  5 

eventration,  235 

gunshot  wounds,  286 

injuries,  284 

operative  wounds,  287 

rupture,  287 

stab-wound,  284 
Diaphragmatic  hernia,  237 
Digestion,  32 

bacterial  action,  40 

gastric,  35 

intestinal,  36 

physiology,  3 1 

prephase,  34 

salivary,  34 
Dilatation,  duodenum,  202 

esophagus,  173 

stomach,  142 
acute,  142 
atonic,  150 
diagnosis,  162 
prognosis,  164 
secondary,  153 
treatment,  16^ 
Diverticulum,  common  duct,  472 


822 


INDEX 


Diverticulum,  duodenum,  20+ 

stomach,  1 88 
Duct,  common,  20 

stone,  469 

stricture,  507 
cystic,  20 

stone,  493 

stricture,  507 
hepatic,  20 

stone,  476 

stricture,  507 
Duodeno-choledochotomy,  784 
Duodenoplasty,  201 
Duodenostomy,  370 

in  carcinoma  stomach,  278 
Duodenum,  benign  diseases,  igo 
carcinoma,  279 
congenital  imperforation,  200 
dilatation,  202 
diverticulum,  204 
excision,  367 
fistula,  401 
foreign  bodies,  308 
gunshot  wounds,  306 
hour-glass,  203 
injuries,  306 
occlusion,  201 
operation,  after-treatment,  316 

anesthetic,  310 

causes  of  death,  371 

instruments,  311 

preparation  of  abdomen,  309 
relations,  6 
rupture,  307 
sarcoma,  281 
sphincter,  28 
stab-wounds,  306 
stenosis,  congenital,  201 

acquired,  201 
stricture,  200 
topography,  27 
tumors,  benign,  205 
ulcer,  190 

diagnosis,  195 

perforation,  194 

prognosis,  196 

symptoms,  192 

treatment,  198 
X-ray,  64 
Dupuytren's  suture,  313 
Durante's  pyloroplasty,  330 
Duret's  gastropexy,  347 
"Dyspepsia  of  Uquids,"  163 


EcHlNOCOCCus  alveolaris,  561 

cyst,  liver,  SS9 

granulosus,  560 

multilocularis,  561 

scolecipariens,  561 
Eck's  fistula,  556 
Egagropile,  304 
Embryology,  6 

Empyema  of  gall-bladder,  431 
Endogastritis  obliterans,  218 
Endothelioma  of  Gaucher,  740,  743 

stomach,  283 
Enterokinase,  37,  39 
Enzymes,  $3 
Epiplopexy,  558 
Erb's  phenomenon,  159 
Erepsin,  39 
Esophagoplasty,  322 
Esophagus,  dilatation,  173 

imperforation,  171 

veins,  varicose,  95 
Eventration,  diaphragm,  235 
Ewald's  test  meal,  S7 
Excision,  duodenum,  367 
stomach,  34S 
ulcer  stomach,  364 
Exclusion  of  pylorus,  344 
"Exulceratio  simplex,"  73 

Falciform  ligament,  17 
Fat  necrosis,  631 
Feces,  composition,  41 

stercobilin,  628 
Fedeli  and  Romanelli's  test,  628 
Fibroma,  liver,  574 

spleen,  735 
Fibromatosis  of  stomach,  218 
Fibromyoma,  stomach,  206 
Finnej^s  pyloroplasty,  326 
Fistula,  biUarj',  524 

postoperative,  529 

duodenal,  401 

Eck's,  556 

gastric,  397 

gastro-colic,  398 

gastro-cutaneous,  397 

jejuno-colic,  401 

mucous,  527 
postoperative,  S28 
Floating  liver,  536 

spleen,  728 
Fluoroscopy,  in  diagnosis,  65 
Food  stuffs,  33 


INDEX 


823 


Foramen  of  Winslow,  11 
Foreign  bodies  in  duodenum.  308 
in  stomach,  303 

GALL-BI.ADDER,  absence,  442 

anomalies,  443 

calculi,  493 

carcinoma,  583 
treatment,  588 

cholesterin,  465 

cystic  degeneration,  583 

disease  during  typhoid,  430 

double,  444 

empyema,  451 

"hour-glass,"  443 

hydrops,  450 

injuries,  607 

operation,  760 
instruments,  766 

perforation,  453 

relations,  $ 

rupture,  traumatic,  607 

sarcoma,  583 

stagnant,  449 

strawberry,  460,  466 

topography,  19 

tumors,  583 

volvulus,  4S4 

wandering,  444 

wound,  penetrating,  610 
Gall-stones,  classification,  425 

intestinal  obstruction,  530 

localization,  492 

common  duct,  494 

cystic  duct,  493 

gall-bladder,  493 

location,  statistics  of,  463 

pathogenesis,  420 

physical  character,  423 

recurrence,  497 
Gangrene,  pancreas,  654 
Gangrenous  cholecystitis,  453 
Gaseous  cyst  stomach,  215 
Gastrectomy,  347 

Billroth's,  353 

in  carcinoma,  275 

circular,  348 

cylindrical,  348,  361 

Hartmann's  line,  252 

Kocher's,  351 

partial,  348,  351 
mortality,  113 

Polya's,  357 


Gastrectomy,  subtotal,  348,  359 

total,  348,  360 
Gastric,  analysis,  56 

artery,  13 

digestion,  35 

fistula,  397 

myasthenia,  150 

tetany,  158 
prognosis,  164 
Gastritis,  phlegmonous,  227 

submucous,  227 
Gastro-anastomosis,  346,  184 
Gastro-colic  fistula,  398 

omentum,  rupture,  302 
Gastro-duodenostomy,  109 

Kocher's,  330 
Gastro-enterostomy,  109 
Gastro-epiploic  artery,  13 

rupture,  302 
Gastro-gastrostomy,  184,  345 
Gastro-hepatic  nerve,  26 

omentum,  rupture,  302 
Gastro-jejunal  ulcer,  389,  392 
Gastro-jejunostomy,  109,  185 

anterior,  341 

Hacker's,  331 

hernia  following,  396 

history,  331 

in-Y,  332 

long-loop,  331 

Murphy-button,  342 

posterior,  334 
in-Y,  343 

Roux's,  332 

short-loop,  m 

vicious  circle,  380 

Wolfler's,  331 
Gastropexy,  347 
Gastroplasty,  183,  345,  364 
GastropHcation,  168,  347 
Gastroptosis,  165 

treatment,  168 
Gastro-pyloro-duodenostomy,  109 
Gastro-splenic  ligament,  718 
Gastrostomy,  318 

in  carcinoma,  278 

Kader's,  320 

Stamm's,  320 

Tavel's,  322 

Witzel's,  319 
Gastrotomy,  316 

Gaucher,  primitive  endothelioma,  743 
Glands,  Brunner's,  32 


824 


INDEX 


Glands,  Lieberkuhn's,  32 
Globus  hystericus,  160 
Glutzinsky's  test,  259 
Glycogen,  39 
Glycosuria,  alimentary,  39 

pancreatic,  629 
Gumma,  liver,  576 

stomach,  225 
Gunshot  wound  diaphragm,  286 

duodenum,  306 

liver,  601 

pancreas,  689 

spleen,  755 

stomach,  291 

Hair-balls,  in  stomach,  304 
Hacker's  gastrojejunostomy,  331 
Hanoi's  cirrhosis,  554 
Haudek's  niche,  65 
Hartmann's  line  for  gastrectomy,  252 
Hemachromatosis,  617,  746 
Hemangeio-endothelio-sarcoma,  liver,  578 
Hemangeioma,  spleen,  735 
Hematemesis,  in  gastric  ulcer,  79 
Hemolytic  blood  test,  259 

icterus,  750 
Hemorrhage,  gastric,  prognosis,  107 

in  gastric  ulcer,  80 
treatment,  n8 

in  jaundice,  436 

in  pancreatic  disease,  632 
Hemorrhagic  pancreatitis,  637 
Hepatectomy,  793 
Hepatic  artery,  22 

duct,  20 

calculus,  476 
stricture,  507 

phlebotomy,  552 
Hepatico-enterostomy,  515 
Hepaticostomy,  503,  514 
Hepaticotomy,  503 
Hepatitis,  suppurative,  540 
Hepatocholangeioenterostomy,  512 
Hepatomphalos,  534 
Hepatope.\y,  539,  790 
Hepatoptosis,  536 
Hepatostomy,  514 
Hepatotomy.  503 

transpleural,  791 
Hernia,  diaphragmatic,  237 

internal,  after  gastro-jejunostomy,  396 
Herzen's  esophagoplasty,  324 
Hodgkin's  disease,  stomach,  218 


Hoffman's  sign,  159 
Hormones,  35 

Hort's  treatment  for  gastric  ulcer,  99 
Hour-glass  duodenum,  203 
gall-bladder,  443 
stomach,  178 

digital  divulsion,  183 

gastrectomy,  186 

gastro-gastrostomy,  184 

gastro-jejunostomy,  185 

gastroplasty,  183 
"Hunger  pain"  in  duodenal  ulcer,  193 
Hydatid  cyst,  gaseous.  563 

liver,  559 
marsupialization,  568 

stomach,  214 
Hydrochloric  acid,  58 
Hydrops,  gall-bladder,  450 

vesicae  fellese,  450 
Hyperemesis  lactantium,  131 
Hyperesthesia,  cutaneous,  3 
Hypertrophy,  pylorus,  131 

Ileocecal  infantile  stenosis,  134 
Imperforate  duodenum,  200 
Incision,  bayonet,  761 

Sevan's,  763 

Collins's,  762 

Courvoisier's,  761 

Czerny's,  763 

Kehr's,  761 

Kocher's,  761 

Langenbuch's,  361 

Riedel's,  761 

Robson's,  761 

Sprengel's  transverse,  763 

Tail's,  761 
Incisura  angularis,  12 
Infantile  stenosis,  pylorus,  131 
Inspection,  54 
Intercostal  nerve,  2 
Intestinal  digestion,  36 
Intestine,  absorption,  39 

movements.  48 

obstruction,  gall-stone,  530 
Invertase,  39 

v.  Jaksch's  pseudoleukemia  infanlium,  748 
Jaundice,  aphorisms,  439 

in  carcinoma  pancreas,  694 

catarrhal,  445 

cholecystitis,  456 

classification,  438 


INDEX 


825 


Jaundice,  hemolytic,  750 

hemorrhage,  436 

as  a  symptom,  434 
Jaworski's  sign,  182 
Jejuno-colic  fistula,  401 
Jejunostomy,  369 

in  carcinoma  of  stomach,  278 
Jejunum,  ulcer,  389 
Jianu's  esophagoplasty,  324 

Kader's  gastrostomy,  320 
Karewski's  jejunostomy,  369 
Kausch's  operation,  591 

Kehr's  incision,  761 

operation,  503,  514 
'Kissing  ulcer,"  17 
Kocher's  gastrectomy,  351 

gastro-duodenostomy,  330 

incision,  761 

Lactase,  39 

Langenbuch's  incision,  761 
Laparotomie  blanche,  130 
Lavage  of  stomach,  61 
Leather-bottle  stomach,  218 
Leiomyoma  malignum,  208 
Lembert  suture,  313 
Leukemia,  myelocytic,  754 
Lieberkiihn's  glands,  32 
Lieno-phrenic  ligament,  719 
Lieno-renal  ligament,  718 
Ligament,  coronary,  17 
falciform,  4,  17 
gastro-splenic,  718 
lateral  of  liver,  18 
lieno-phrenic,  719 
lieno-renal,  718 
spleen,  718 
suspensory  of  liver,  4 
of  Treitz,  27 
Lipase,  33 

Lipoma,  siomach,  213 
Lipomatosis,  668 
Liver,  abscess,  540 
amebic,  540 
classification,  540 
pathology,  544 
pyemic,  540 
symptoms,  547 
transpleural  hepatotomy,  791 
traumatic,  540 
treatment,  552 
tropical,  540 


Liver,  adenoma,  574 
angeiomata,  574 
anomalies,  534 
blood  supply,  22 
carcinoma,  579 
cirrhosis,  553 

biliary,  554 

operations,  556 

portal,  553 
coronary  ligament,  17 
"corset,"  534 
"corset-furrow,"  534 
cyst,  559 

echinococcus,  559 

hydatid,  559 
treatment,  567 

non-parasitic,  573 
cystadenoma,  575 
falciform  ligament,  4,  17 
fibromata,  574 
floating,  536 
gummata,  576 

hemangeio-endothelio-sarcoma,  578 
injuries,  593 
internal  secrections,  43 
lateral  ligament,  18 
ligaments,  17 
linguiform  lobulation,  535 
location,  5 
lymphatics,  25 
lymphosarcoma  578 
movable,  536 
myomata,  574 
myosarcoma,  578 
myxosarcoma,  578 
nerves,  26 
operations,  790 
passive  congestion,  536 
physiology,  41 
Riedel's  lobe,  535 
rupture,  595 

treatment,  599 
sarcoma,  577 

melanotic,  578 
surgery,  534 
syphiloma,  576 
topography,  17 
tuberculoma,  577 
tumors,  574 

malignant,  577 
veins,  23 

"  wandering  lobe,"  535 
wound,  gunshot,  601 


826 


INDEX 


Liver,  wound,  stab,  604 
"Liver  pouch,"  26 
Lowi's  test,  624 
"Luschka's  Gange,"  453 
Lymphadenoma,  stomach,  217 
Lymphangeiomatous  cyst,  stomach,  215 
Lymphosarcoma,  liver,  578 
Lymphatics,  liver,  25 

pancreas,  30,  660 

stomach,  13 

McBurney's  operation,  784 

Mackenzie,  viscero-muscular  reflex,  3 

Magenschrumpfung,  218 

Malarial  splenomegaly,  752 

Maltase,  39 

Mammary  artery,  internal,  2 

Marginal  ulcer,  389 

Marsupialization,  hydatid  cyst  li\er,  568 

Mattress  suture,  313 

Maydl's  jejunostomy,  369 

Mensuration,  56 

Metastasis  in  carcinoma  stomach,  251 

Movable  liver,  536 

spleen,  728 
Mucous  fistula,  527 
Muller's  test,  627 
Muscle,  rectus,  i 
Muscular,  rigidity,  3 
Myelocytic  leukemia,  754 
Myoma,  liver,  574 

sarcomatodes,  stomach,  208 

stomach,  206 
Myosarcoma,  liver,  578 
Myxoma  stomach,  213 
Myxomyoma  stomach,  207 
Myxosarcoma,  liver,  578 

Necrosis,  fat,  631 
Nerve,  gastro-hepatic,  26 

intercostal,  2 

pneumogastric,  14 
Nerves,  liver,  26 

pancreas,  30 

stomach,  14 
Nicoll's  pyloroplasty,  137 
Non-calculous  cholecystitis,  454 

Obstkuction,  biliary  passages,  506 
.  from  external  cause,  521 
cystic  duct,  469 
intestine,  gall-stone,  530 
pylorus,  131 


Occlusion,  duodenum,  201 

pylorus,  116 
Oddi,  sphincter,  38 
Omentopexy,  170,  558 
Operation,  anesthetic,  310 

ante-thoracic  esophago- jejunostomy, 

323 
bile-duct,  760 
cardioplasty,  175 
cholecystectomy,  773 
cholecystendysis,  766 
chdecystenterostomy,  515,  787 
cholecysto-colostomy,  787 
cholecysto-duodenostomy,  787 
cholecysto-gastrostomy,  787 
cholecysto-jejunostomy,  787 
cholecystostomy,  767 

with  prolonged  drainage,  772 
cholecystotomy,  767 

without  drainage,  766 
choledocho-enterostomy,  510 
choledochoplasty,  509 
choledochotomy,  777 

retroduodenal,  784 

transduodenal,  782 
Cranwell's,  242 
Depage's  791 

duodeno-choledochostomy,  784 
duodeno-choledochotomy,  784 
duodeno-pancreatectomy,  702 
duodenoplasty,  201 
duodenostomy,  n8,  370 
duodenum,  causes  of  death,  371 

complications,  371 
esophagoplasty,  322 
excision,  duodenum,  367 

stomach,  348 

ulcer,  stomach,  in 

Finney's,  326 
gall-bladder,  760 

instruments,  766 
gastrectomy,  347 

Billroth's,  353 

circular,  348 

cylindrical,  348,  361 

Kocher's,  351 

partial,  348,  351 

Polya's,  357 

subtotal,  348,  359 

total,  348,  360 
gastric  resection.  348 
gastro-anastomosis.  184,  346 
gastro-duodenostomy,  109 


INDEX 


827 


Operation,  gastro-duodenostomy,  Kocher's, 
330 
gastro-enterostomy,  109 
gastro-gastrostomy,  184,  345 
gastro-jejunostomy,  109,  185, 
anterior,  341 
Hacker's,  331 
in-Y,  332 
posterior,  334 

in-Y,  343 
vicious  circle,  380 
Wolfler's,  331 
gastropexy,  347 
gastroplication,  168,  347 
gastroplasty,  183,  345,  364 
gastro-pyloro-duodenostomy,  109 
gastrostomy,  318 
gastrotomy,  316 
hepatectomy,  793 
hepaticostomv,  514 
hepatocholangeioenterostomy,  512 
hepatopexy,  S39.  79° 
hepatostomy,  514 
hepatotomy,  transpleural,  791 
Herzen's  esophagoplasty,  324 
incisions,  761 
jejunostomy,  118,  369 
Jianu's  esophagoplasty,  324 
Kausch's,  591 
Kehr's,  503,  514 
liver,  790 
McBurney's,  784 
omentopexy,  170 
pancreas,  795 
pancreatectomy,  795 
total  cephalic,  796 
pancreato-enterostomy,  797,  799 
pancreatostomy,  688 
pylorectomy,  348 
Billroth's,  349 
pyloroplasty,  109,  326 
Durante's,  330 
Finney's,  326 
resection,  cardia,  366 
common  duct,  509 
stomach,  348,  363 
Roux's,  322 
Rydygier's,  242 
sphincterectomy,  347 
splenectomy,  799 
splenopexy,  804 
splenotomy,  803 
stomach,  causes  of  death,  371 


Operation,  stomach,  complications,  37r 
preparation,  309 

Talma's,  558 

technique,  760 

Terrier's,  775 
Osteoma,  spleen,  735 

stomach,  217 

Pain,  in  carcinoma  pancreas,  695 
in  carcinoma  stomach,  257 
in  cholecystitis,  454 
in  cholelithiasis,  482 
in  duodenal  ulcer,  193 
in  gastric  ulcer,  75 
in  pancreatic  calculi,  685 
in  pancreatitis,  acute,  642 

chronic,  672 
shoulder-blade,  4 
Palpation,  54 
Pancreas,  abscess,  654 
accessory,  612 
adenoma,  703 
annulare,  613 
anomalies,  612 
blood  supply,  29 
calculus,  621,  685 
carcinoma,  691 

diagnosis,  699 

treatment,  701 
cyst,  704 

diagnosis,  712 

treatment,  714 
disease,  diagnosis,  626,  633 
displacement,  614 
divisum,  613 
gangrene,  654 
gunshot  wound,  689 
infections,  614 

through  the  blood,  614 

by  contiguity,  621 

through  the  ducts,  617 

through  the  lymphatics,  620 
injuries,  689 
internal  secretions,  43 
lymphatics,  30,  660 
minus,  613 
nerves,  30 
operations,  795 
perforation,  637 
relations,  6 
resection,  701 
ring-formed,  613 
rupture,  689 


828 


INDEX 


Pancreas,  sarcoma,  703 
stab-wound,  68q 
surgery,  611 
topography,  29 
"triangle  of  infection,"  (JiS 
tumors,  691 
Pancreatectomy,  795 

total  cephalic,  796 
Pancreatic  apoplexy,  638 
colic,  685 
diabetes,  623 
disease,  Lowis  test,  624 
glycosuria,  629 
juice,  36 

lymphangeitis,  620,  659 
point  of  Desjardins,  677 
urine  reaction,  678 
Pancreatico-hepatic  area,  677 
Pancreatitis,  acute,  636 

diagnosis,  differential,  644 
etiology,  639 
morbid  anatomy,  640 
prognosis,  646 
symptoms,  641 
treatment,  650 
chronic,  658 
catarrhal,  658 
diagnosis,  679 
interstitial,  667 
operation,  statistics,  684 
treatment,  680 
hemorrhagic,  637 
subacute,  654 

treatment,  655 
suppurative,  654 
Pancreato-enterostomy,  797,  790 
Pancreatostomy,  688 
Papilla  of  Vater,  22 
Papilloma,  stomach,  209 
"Paradoxical  dilatation,"  182 
Para-umbilical  veins,  24 
Pepsin,  33 
Percussion,  55 

Perforation,  carcinoma,  stomach,  255 
gall-bladder.  453 
pancreas,  637 
ulcer,  duodenum,  194 
stomach,  83 
Pericholecystic  abscess,  467 
Pericholecystitis,  452 
Perigastric  adhesions,  155 
Peritoneum,  embryology,  6 
Peritonitis,  biliary,  452 


Peritonitis,  post-operative,  378 
Pernicious  anemia,  752 
"Phlegmon  ventriculi,"  227 
Phlegmonous  cholecystitis,  453 

gastritis,  227 
Physiology,  applied,  49 

of  digestion,  31 

of  liver,  41 

spleen,  719 
Plastic  linitis,  218 
Pneumogastric  nerve,  14 
Pneumokystes  hydatiques,  563 
Pneumonia,  post-operative,  377 
Polya's  gastrectomy,  357 
Polyadenomata,  stomach,  211 
"Polyadenome  en  nappe,"  211 
Polyp,  stomach,  mucous,  211 
Portal  thrombosis,  524 

vein,  24 
Pro-secretin,  36 
Pseudoleukemia  infantium,  748 

splenic,  739 
Ptyalin,  34 

"Punched  out"  ulcer,  73 
Pylorectomy,  348 

Billroth's,  349 
Pyloric  artery,  13 
Pyloroplasty,  109,  326 

Durante's,  330 

Finney's,  326 

Nicoll's,  137 

Rammstedt's,  137 

Strauss's,  140 
Pylorospasm,  141 
Pylorus,  atresia,  132 

exclusion,  344 

hypertrophy,  131 

infantile  stenosis,  131 

obstruction,  131 

occlusion,  116 

scirrhus,  131 

Rammstedt's  pyloroplasty,  137 
Ranula  pancreatica,  706 
Rectus  muscle,  i 
Rennin,  36 
Resection,  cardia,  366 

common  duct,  509 

pancreas,  701 

stomach,  363 
Retroduodenal  choledochotomy,  7S4 
Riedel's  incision,  761 

lobe,  535 


INDEX 


829 


Rigidity,  "board-like,"  86 

muscular,  3 
Robson's  incision,  761 

point,  488,  677 
Roux  s  esophagoplasty,  322 

gastro-jejunostomy,  332 
Rupture,  bile-duct,   607 

diaphragm,  287 

duodenum,  307 

gall-bladder,   607 

gastro-colic  omentum,  302 

gastro-epiploic  artery,  302 

gastro-hepatic  omentum,  302 

liver,  595 

pancreas,  689 

stomach,  296 
interstitial,  301 
spontaneous,  297 
Rydygier's  operation,  24.2 

Sahli's  test,  628 
Salivary  digestion,  34 
Salomon's  test,  259,  62,S 
Sarcoma,  duodenum,  281 

gall-bladder,  583 

liver,  S77 

melanotic,  578 

pancreas,  703 

spleen,  735 

stomach,  281 
Schlesinger's  phenomenon,  159 
Schmidt's  test,  627 
Sclerosis,  stomach,  218 
Secretin,  36,  39 
Segmented  stomach,  178 
Selective  vomiting,  46 
Sero-serous  suture,  312 
Serum,  antilytic,  99 
Shock,  post  operative,  376 
Shoulder-blade  pain,  4 
"Shoulder-tip  pains,"  26 
Sialodochitis  pancreatica,  658 
Sialorrhea  pancreatica,  629 
"Sleeve-resection"  stomach,  361 
Sphincter,  duodenal,  28 

of  Oddi,  38 
Sphincterectomy,  347 
Spleen,  abscess,  736 

accessory,  719 

anatomy,  717 

anomalies,  719 

blood-vessels,  718 

cavernous  angeioma,  735 


Spleen,  chondroma,  735 

cyst,  732 

dislocated,  728 

ectopic,  728 

enlargements,  723 

ferment,  722 

fibroma,  735 

floating,  728 

function,  blood-forming,  720 
metabolic,  721 

gunshot  wound,  755 

hemangeioma,  735 

injuries,  754 

internal  secretion,  722 

ligaments,  718 

lymphangeioma,  735 

movable,  728 

movements,  722 

operations,  799 

osteoma,  735 

physiology,  719 

prolapse,  728 

relations,  6 

rupture,  754 
operation,  75S 

sarcoma,  735 

stab-wound,  755 

surgery,  717 

syphilis,  736 

torsion,  729 

tuberculosis,  735 

tumors,  735 

wandering,  728 
Splenic  artery,  718 

aneurysm,  splenectomy,  759 

anemia,  739 

lymphadenoma,  739 

pseudoleukemia,  739 
Splenitis,  suppurative,  736 
Splenectomy,  799 

for  aneurysm  splenic  artery,  759 

in  Banti's  disease,  749 

in  cirrhosis  of  liver,  557 

in  pernicious  anemia,  752 

results,  720 
Splenocleisis,  750 
Splenomegalic  cirrhosis,  740 
Splenomegaly,  723 

idiopathic,  740 

in  childhood,  748 

malarial,  752 

with  anemia,  739 
Splenopexy,  804 


830 


INDEX 


Splenoptosis,  728 
Splenotomy,  803 
Sprengel's  incision,  763 
Stab-wound,  diaphragm,  2S4 
duodenum,  306 
gastro-epiploic  artery,  291 
liver,  604 
pancreas,  689 
spleen,  755 
stomach,  288 
Stagnant  gall-bladder,  449 
Stamm's  gastrostomy,  320 
Steapsin,  33 
Steatorrhea,  627 
"Steeple"  chart,  491 
Stenosis,  duodenum,  201 
Stercobilin  in  feces,  628 
Stomach,  adenoma,  209 
angeioma,  217 
antrum,  cardiac,  12 

pyloric,  12 
blood  vessels,  13 
carcinoma,  244 

clinical  pathology,  249 
diagnosis,  260 
duodenostomy,  278 
extension  by  contiguity,  254 
gastrectomy,  275,  278 
Glutzinsky's  test,  259 
hemolytic  blood  test,  259 
jejunostomy,  278 
metastasis,  251 
pain,  257 
perforation,  255 
prognosis,  263 
resection,  277 
Salomon's  test,  259 
secondary,  255 
treatment,  275 
vomiting,  257 
cardia,  obstruction,  177 
cirrhosis,  218 
concretions,  217 
cysts,  213 
dilatation,  142 
acute,  142 
atonic,  150 
secondary,  153 
diffuse  sclerosis,  218 
diverticulum,  i88 
endothelioma,  283 
excision,  348 
extraperitoneal,  13 


Stomach,  fibromatosis,  218 
fibromyoma,  206 
foreign  bodies,  303 
gumma,  225 
hair-balls,  304 
hemorrhage,  prognosis,  107 
Hodgkin's  disease,  218 
hour-glass,  178 

gastrectomy,  186 

gastro-gastrostomy,  184 

gastroplasty,  183 
injuries,  28S 
lavage,  61 

leiomyoma  malignum,  208 
leather-bottle,  218 
lipoma,  213 
lymphadenoma,  217 
lymphatics,  13 
motor  function,  56 
movements,  45 
myoma,  206 

sarcomatodes,  208 
myxoma,  213 
myxomyoma,  207 
nerves,  14 
operation,  after-treatment,  316 

anesthetic,  310 

causes  of  death,  371 

instruments,  311 

preparation,  309 
of  abdomen,  309 

suture,  311 

technique,  310 
osteoma,  217 
papilloma,  209 
polyadenomata,  211 
"polyadenome  en  nappe,"  211 
polyp,  mucous,  211 
posterior  wall,  exposure,  16 
relations,  5 
resection,  348,363 

cardia,  366 
rupture,  296 

interstitial,  301 

spontaneous,  297 

traumatic,  299 
sarcoma,  281 
sclerosis,  218 
segmented,  178 
"sleeve-resection,"  361 
stab-wounds,  288 
surgical  diseases,  S3 
syphilis,  224 


INDEX 


831 


Stomach,  syphiloma,  225 
topography,  12 
tube,  59 

tuberculosis,  221 
treatment,  223 
tumors,  benign,  205 
ulcer,  67 

actual  cautery,  116 
callous,  73 
carcinoma,  245 
chronic,  73 
diagnosis,  92 
duodenostomy,  118 
excision,  iii,  364 
mortality,  113 
transgastric,  364 
end  results,  104 
hematemesis,  79 
hemorrhage,  80 

treatment,  118 
histology,  250 
Hort's  treatment,  99 
jejunostomy,  118 
operations,  102 
pain,  75 

referred,  78 
pathogenesis,  67 
pathology,  70 
perforation,  83 
diagnosis,  87 
prognosis,  108 
treatment,  120 
prognosis,  97 
"punched  out,"  73 
round,  75 
simple,  73 

Sippy's  treatment,  loo 
symptoms,  75 
treatment,  109 
volvulus,  230 
X-ray,  63 
"Strawberry  gall-bladder,"  460,  466 
Stricture,  bile-ducts,  507 
congenital,  441 
choledochostomy,  513 
duodenum,  200 
Subphrenic  abscess,  402 
diagnosis,  407 
treatment,  409 
Succus  entericus,  38 
Sulcus,  intermedins,  12 
Suppurative  hepatitis,  540 
"Suppurative  linitis,"  227 


Suture,  Cushing's,  313 
Dupuytren's,  313 
Lembert,  313 

mattress,  313 
sero-serous,  312 
"splint,"  315 
Syphilis,  liver,  576 
spleen,  736 
stomach,  224 

T^NiA  echinococcus,,  560 
Tail's  incision,  761 
Talma's  operation,  558 
Tavel's  gastrostomy,  322 
Teeth,  50 

Terrier's  operation,  775 
Test,  Cammidge,  636 

Fedeli  and  RomaneUi's,  628 

Lowi's,  624 

Miiller's,  627 

Sahli's,  628 

Salomon's,  628 

Schmidt's,  627 
Test  meal,  Boas,  57 

Ewald's,  57 
Tetany,  gastric,  158 
prognosis,  164 
Thrombosis,  portal,  524 
Torsion,  spleen,  729 

Transduodenal  choledochotomy,  502,  782 
"Triangle  of  infection,"  618 
Traumatic  cyst,  stomach,  214 
Treitz  ligament,  27 
Trichobezoar,  304 
Trousseau's  phenomenon,  159 
Tuberculoma,  liver,  577 
Tuberculosis,  spleen,  735 

stomach,  221 
treatment,  223 
Tumors,  duodenum,  205 

gall-bladder,  583 

liver,  574 

pancreas,  691 

spleen,  73s 

stomach,  205 
Typhoid  carriers,  432 

fever,  gaU-bladder  disease,  430 

infection  of  biliary  tract,  427 

Ulcer,  duodenum,  190 
causes,  192 
diagnosis,  195 
"hunger  pain,"  193 


8.^,2 


INDEX 


Ulcers,  duodenum,  location,  ig2 
perforation,  ig4 
prognosis,  ig6 
symptoms,  192 
treatment,  198 
gastric,  67 

gastro-jejunal,  380,  392 
jejunum,  389 
kissing,  71 
marginal,  389 
stomach,  67 

actual  cautery.  116 
callous,  73 
chronic,  73 
diagnosis,  92 
duodenostomy,  118 
end  results,  104 
excision,  iir,  364 
mortality,  113 
transgastric,  364 
hematemesis,  79 
hemorrhage,  80 

treatment,  iiS 
histology,  250 
Hort's  treatment,  99 
in  carcinoma,  245 
jejunostomy,  118 
operations,  102 
pain,  75 

pathogenesis,  67 
pathology,  70 
perforation,  83,  400 
diagnosis,  87 
prognosis,  108 
treatment,  120 
pain,  referred,  78 
prognosis,  97 
"punched  out,"  73 
round,  75 
simple,  73 
symptoms,  75 
treatment,  109 
vomiting,  78 
Ulcus  carcinomatosum.  250 
Umbilicus,  4 


Vater,  ampulla,  22 

papilla,  22 
Vein,  liver,  23  • 

portal,  24 

para-umbilical,  24 

varicose,  gastric,  95 
Vicious  circle,  380 

Viscero-muscular  reflex  of  JMackenzie,  3 
Volvulus,  gall-bladder,  454 

stomach,  230 
Vomiting,  in  carcinoma  stomach,  257 

in  cholelithiasis,  492 

in  duodenal  ulcer,  193 

in  gastric  ulcer,  78 

in  pancreatitis,  acute,  642 

mechanism,  48 

selective,  46 

Wall,  abdominal,  : 
Wandering  gall-bladder,  444 

spleen,  728 
"Wandering  lobe"  of  liver,  535 
"Wellenschnitt,"  761 
Witzel's  gastrostomy,  319 
Wolfler's  gastro-jejunostomy,  331 

sign,  182 
Wound,  abdominal,  closure,  314 
gunshot,  diaphragm,  286 

duodenum.  306 

liver,  601 

pancreas,  689 

spleen,  755 

stomach,  291 
stab,  diaphragm,  284 

duodenum,  306 

gastro-epiploic  artery,  291 

liver,  604 

pancreas,  689 

spleen,  755 

stomach,  288 

Xa.\thelasm.-v,  435 
Xanthoma,  435 
X-ray,  in  diagnosis,  61 

ZUCKERGUSSMAGEN,  2l8 


Date  Due 

(5?J                              CAT.    NO.    23    233                            PRINTED    IN    U.S. A 

■-  / 


'(>/ 


SOUTHERN  REGIONAL  LIBRARY  FACILITY 


D  000  165  091  0 


P 

m 
m 

o 
-n 

o 

t/i 

— I 
m 

O 


WI  900 

D285S 

1921 


')eaver,  John  B 

S\u-g€ry  of  the  upper  abdomen 


I 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


-.5' 


1 

;» 

■  1 

■  ■> 

■'i 


#:^:''':-'/#^ 


1,1 


.,1 

.,1 

.'1 
..« 

1 


:'.v;v;^'v-^(" 


